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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 6.00 $360.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 4 7.50 $562.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 40 62 100.50 $7537.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 26 21.72 $1053.53 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 17.01 $824.77 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 62 64 65.53 $3178.17 $48.50
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Subtotal (Total Children Is Unduplicated) 138 193 232.26 $14364.55 $61.85
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 8 6.46 $322.78 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 16.05 $802.39 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 16.78 $839.05 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 17.11 $855.72 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.18 $29.58 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 7.63 $381.67 $50.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 12.00 $150.00 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.71 $117.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 174 184 1154.95 $57747.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 34.29 $1714.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 50 55 352.93 $23956.79 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 16 70.95 $3853.97 $54.32
PHY -97110 PT SESSION BY LICENSED PT 55 63 439.00 $29799.64 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 13 62.57 $3398.89 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 34.61 $34.61 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 4 4 4.36 $81.54 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 122 752.73 $51095.09 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.43 $23.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 29 31 195.29 $2577.77 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 27.79 $1389.29 $50.00
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Subtotal (Total Children Is Unduplicated) 353 566 3214.31 $179734.25 $55.92
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Total 759 3446.57 $194098.79 $56.32
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Number of Children (Unduplicated) With at Least One Authorization 420