Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 12 12.00 $582.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 10.00 $600.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.00 $100.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 26 26 43.04 $2151.79 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 11.50 $862.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 15.50 $860.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 141 141 194.00 $14550.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 11.00 $825.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 47 48 82.14 $6160.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 167 167 228.86 $12701.57 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 141 145 198.36 $14876.79 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.00 $388.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $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) 318 599 829.39 $55448.12 $66.85
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 18 18.00 $27000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 30 31 38.14 $1907.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 7 3.25 $81.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 7.97 $398.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 15.90 $397.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 8.90 $445.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 5.77 $144.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 20.41 $1020.35 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 24.33 $608.30 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 94.93 $2373.22 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 160 167 1035.69 $51784.30 $50.00
INTR -INTR INTERPRETER 21 22 118.89 $5944.65 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 47 49 366.86 $24902.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 18.71 $1016.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 84 94 632.91 $42961.95 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 10.29 $558.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 32 32 33.31 $33.31 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 13.14 $657.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 216 233 1519.73 $103159.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 26 26 213.00 $2811.59 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 356 521 2731.49 $1365.74 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 10.00 $500.00 $50.00
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Subtotal (Total Children Is Unduplicated) 461 1264 6946.61 $270289.78 $38.91
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Total 1863 7776.01 $325737.90 $41.89
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Number of Children (Unduplicated) With at Least One Authorization 553