Summary Report for FSPSAs Ending During the Report Period Center: 03
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
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 13 13 19.00 $1425.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 15.00 $1125.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 38 38 66.50 $3690.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 6.50 $487.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 30 33 40.43 $1960.79 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 20.00 $970.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 36 40 40.00 $1940.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 20 20 20.00 $970.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 91 99 99.00 $4801.50 $48.50
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Subtotal (Total Children Is Unduplicated) 200 315 393.93 $22330.04 $56.69
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.94 $96.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 80 87 127.00 $6350.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 73 78 121.81 $6090.64 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 27 46.00 $2300.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 31 55.65 $2782.39 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 70 100.66 $5032.95 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 100 109 644.45 $32222.39 $50.00
INTR -INTR INTERPRETER 6 9 23.22 $1160.84 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 52 337.41 $22903.27 $67.88
PHY -97110 PT SESSION BY LICENSED PT 54 60 375.29 $25474.39 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 22 20.81 $20.81 $1.00
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 94 107 592.17 $40196.67 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 5.07 $253.57 $50.00
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Subtotal (Total Children Is Unduplicated) 231 658 2455.47 $144972.33 $59.04
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Total 973 2849.40 $167302.37 $58.71
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Number of Children (Unduplicated) With at Least One Authorization 291