Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 47 47 87.79 $6583.93 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 5.00 $375.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 41 41 41.00 $1988.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 19 19.00 $921.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 48 54 54.00 $2619.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 29 30 36.71 $1780.64 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 104 116 116.00 $5626.00 $48.50
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Subtotal (Total Children Is Unduplicated) 207 315 365.50 $20230.57 $55.35
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 126 138 168.03 $8401.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 127 129 184.63 $9231.74 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 57 85.44 $4272.14 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 61 81.54 $4077.14 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 121 161.09 $8054.41 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 136 142 922.79 $46139.58 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.43 $121.67 $50.00
INTR -INTR INTERPRETER 8 9 130.00 $6500.01 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 54 58 421.64 $28621.13 $67.88
PHY -97110 PT SESSION BY LICENSED PT 68 80 515.90 $35019.31 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 54 54 54.00 $54.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 113 759.91 $51582.66 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.61 $580.48 $50.00
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Subtotal (Total Children Is Unduplicated) 308 969 3503.03 $202755.92 $57.88
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Total 1284 3868.53 $222986.49 $57.64
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Number of Children (Unduplicated) With at Least One Authorization 325