Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 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 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 45 46 91.00 $4550.00 $50.00
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 -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 25 25 43.50 $3262.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 5.50 $412.50 $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 20 20 38.00 $2850.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 6.57 $318.71 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 6.20 $300.70 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 128 211 388.54 $24674.87 $63.51
EI Services, Class # 03
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
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 9.82 $490.84 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.28 $32.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 8 10.43 $521.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.28 $32.08 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 47.14 $589.29 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 128.57 $3214.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 63 66 381.25 $19062.64 $50.00
INTR -INTR INTERPRETER 2 2 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 16 16 82.64 $5609.81 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.07 $329.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 13 13 88.46 $6004.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 3.57 $194.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 9.00 $9.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 20 110.89 $7526.92 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.14 $15.09 $13.20
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Subtotal (Total Children Is Unduplicated) 112 164 901.31 $44569.94 $49.45
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Total 375 1289.85 $69244.82 $53.68
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Number of Children (Unduplicated) With at Least One Authorization 174