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: 01/01/08 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 3 3 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 10.00 $500.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 18 19 22.00 $1100.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.50 $112.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.50 $83.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 134 135 237.36 $17801.78 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 88 91 127.50 $9562.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 69 69 90.03 $6752.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 206 213 314.35 $17446.55 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 36 38 49.00 $3675.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 5.29 $256.36 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 16 16.00 $776.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 20 20.00 $970.00 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.00 $200.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 299 630 909.53 $59869.01 $65.82
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 7.33 $366.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 6.88 $343.89 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 3.77 $94.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 16 39.05 $1952.62 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 6 5.00 $125.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 17 69.48 $3473.82 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 9 18.08 $452.08 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 7 5.55 $277.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 4 7.75 $193.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 28 111.38 $5569.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 11 18.28 $457.08 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 12 13 5957.43 $74467.86 $12.50
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 30 30 201.10 $10055.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 121 2226.69 $111334.34 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 26.43 $1321.43 $50.00
INTR -INTR INTERPRETER 9 10 17.75 $887.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 59 74 1169.85 $79409.64 $67.88
OCCT -97530HM OT SESSION BY OT ASST 27 29 438.92 $23842.26 $54.32
PHY -97110 PT SESSION BY LICENSED PT 37 54 924.16 $62732.02 $67.88
PHY -97110HM PT SESSION BY PT ASST 26 30 377.34 $20496.85 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.50 $75.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 96 1854.25 $125866.35 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.43 $838.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 43 53 1024.50 $13523.34 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 34.00 $3400.00 $100.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 15.21 $760.72 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 26.43 $1321.43 $50.00
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Subtotal (Total Children Is Unduplicated) 270 643 14620.54 $561642.57 $38.41
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Total 1276 15533.07 $621511.58 $40.01
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Number of Children (Unduplicated) With at Least One Authorization 430