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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT TRANSITION ASSESSMENT 10 10 10.00 $500.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 53 53 88.29 $6621.43 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 25 36.00 $2700.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 17.53 $1315.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 64 67 105.29 $5843.36 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 7.50 $562.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 6 6.00 $291.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 90 185 275.60 $18127.28 $65.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.23 $11.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 2.25 $112.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.00 $50.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.67 $283.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.25 $56.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.42 $20.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 6.95 $347.51 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 5.05 $126.25 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 517.14 $6464.29 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 33 36 211.57 $10578.34 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 10.43 $521.43 $50.00
INTR -INTR INTERPRETER 3 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 20 21 112.60 $7643.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 49.80 $2704.95 $54.32
PHY -97110 PT SESSION BY LICENSED PT 11 13 72.86 $4945.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 10 25.13 $1365.13 $54.32
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 25 166.79 $11321.41 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 60.54 $799.10 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 14.00 $1400.00 $100.00
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Subtotal (Total Children Is Unduplicated) 93 169 1276.66 $53626.82 $42.01
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Total 355 1553.27 $71754.10 $46.20
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Number of Children (Unduplicated) With at Least One Authorization 169