Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 26 26 52.00 $2600.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $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 54 54 99.20 $7440.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 42.50 $3187.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 6.50 $487.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 48 48 87.57 $4859.95 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 37.00 $2775.00 $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 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 6.57 $318.71 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.00 $194.00 $48.50
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Subtotal (Total Children Is Unduplicated) 109 191 347.34 $22560.17 $64.95
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 9.25 $462.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 6 5.50 $275.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.09 $2.30 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.25 $112.50 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.70 $42.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 4.97 $248.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.46 $136.49 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 189.29 $2366.07 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 70 473.22 $23660.99 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 19 19 83.27 $5652.47 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 7 34.18 $1856.45 $54.32
PHY -97110 PT SESSION BY LICENSED PT 19 19 179.24 $12166.85 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 11.86 $644.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 10 19.00 $19.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.00 $200.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 32 224.79 $15258.47 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 3.00 $39.66 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 1.36 $67.86 $50.00
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Subtotal (Total Children Is Unduplicated) 130 198 1254.42 $63286.51 $50.45
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Total 389 1601.75 $85846.68 $53.60
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Number of Children (Unduplicated) With at Least One Authorization 207