Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.19 $7.19 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.19 $7.19 $37.00
Screening, Eval, and Assessment, Class # 02
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 32 48 81.50 $6112.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 26 22.95 $1113.08 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 30 30 25.69 $1246.03 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 58 58 61.69 $2992.14 $48.50
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Subtotal (Total Children Is Unduplicated) 123 165 195.84 $11671.75 $59.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 10.71 $535.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 4 6.83 $341.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 6.78 $339.17 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.45 $11.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 6.18 $309.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 3.52 $175.83 $50.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 62.57 $782.14 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 9.14 $228.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 176 189 1134.77 $56738.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 7.03 $351.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 24 24 138.07 $9372.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 19 20 88.25 $4793.61 $54.32
PHY -97110 PT SESSION BY LICENSED PT 44 46 350.71 $23806.18 $67.88
PHY -97110HM PT SESSION BY PT ASST 21 21 134.29 $7294.39 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 5.80 $5.80 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 95 558.10 $37884.14 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 26 27 201.29 $2656.98 $13.20
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Subtotal (Total Children Is Unduplicated) 319 465 2727.50 $147226.99 $53.98
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Total 631 2923.53 $158905.93 $54.35
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Number of Children (Unduplicated) With at Least One Authorization 385