Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 12.71 $1589.29 $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 39 60 97.50 $7312.50 $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 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 26 18.34 $889.45 $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 22 22 16.18 $784.63 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 70 61.29 $2972.78 $48.50
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Subtotal (Total Children Is Unduplicated) 132 201 233.53 $15196.73 $65.08
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 7 7 5.77 $288.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 5.31 $265.56 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 15.60 $779.88 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 7.95 $397.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 11.12 $555.84 $50.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 26.00 $325.00 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 164 168 1147.31 $57365.51 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 49 53 355.14 $24107.10 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 57.86 $3142.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 46 49 395.60 $26853.17 $67.88
PHY -97110HM PT SESSION BY PT ASST 17 17 88.79 $4822.84 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 30 38.27 $38.27 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 109 113 786.50 $53387.63 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 18.29 $993.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 16 16 84.93 $1121.06 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.32 $615.95 $50.00
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Subtotal (Total Children Is Unduplicated) 343 507 3059.24 $175140.92 $57.25
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Total 708 3292.77 $190337.65 $57.80
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Number of Children (Unduplicated) With at Least One Authorization 361