Summary Report for FSPSAs Ending During the Report Period Center: 55
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 01/01/09 and 03/31/09 Date of Report: 05-18-09 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 11 11 10.16 $492.55 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 14 14.00 $679.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 12.17 $590.09 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 41 42 41.17 $1996.85 $48.50
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Subtotal (Total Children Is Unduplicated) 59 88 85.49 $4157.98 $48.63
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 1.30 $65.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 5.93 $296.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.90 $45.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 8.71 $435.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 27 210.07 $10503.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 53 54 328.89 $22325.26 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 28.79 $1563.64 $54.32
PHY -97110 PT SESSION BY LICENSED PT 41 42 251.43 $17066.98 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 36.24 $1968.45 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 2.57 $2.57 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 95 521.81 $35420.63 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 40.36 $532.71 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 56 81 3002.22 $1501.11 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 134 324 4445.22 $93477.29 $21.03
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Total 412 4530.71 $97635.28 $21.55
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Number of Children (Unduplicated) With at Least One Authorization 147