Summary Report for FSPSAs Initiated During the Report Period Center: 06
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting between: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 5 6 6.00 $291.00 $48.50
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 5.05 $252.50 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 19 21.00 $1050.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.23 $11.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 4.78 $119.38 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 16.65 $832.62 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.28 $31.88 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 14.06 $702.80 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.18 $4.38 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 10.81 $540.42 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.63 $40.63 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 26 29 328.71 $8217.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 131 143 804.10 $40204.96 $50.00
INTR -INTR INTERPRETER 14 14 38.71 $1935.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 41 42 163.26 $11081.86 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 33.46 $1817.78 $54.32
PHY -97110 PT SESSION BY LICENSED PT 73 83 308.70 $20954.22 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 9 24.50 $1330.85 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 15.50 $15.50 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 157 175 692.97 $47038.89 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 22 26 141.00 $1861.20 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 8.64 $432.15 $50.00
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Subtotal (Total Children Is Unduplicated) 348 611 2641.21 $144602.22 $54.75
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Total 617 2647.21 $144893.22 $54.73
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Number of Children (Unduplicated) With at Least One Authorization 349