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: 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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.00 $450.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 22 23 29.00 $1450.00 $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 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 18 18.00 $873.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 19 21 21.00 $1018.50 $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) 297 637 916.24 $60209.53 $65.71
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 10.00 $15000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 8.33 $416.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 20.25 $1012.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 3.77 $94.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 17 40.05 $2002.62 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 10 10 9.00 $225.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 14 52.28 $2613.82 $50.00
CONOP -CONOP CONSULT, OT, PHONE 12 13 25.95 $648.75 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 5 1.50 $75.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 6.38 $159.58 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 26 95.96 $4798.23 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 13 20.62 $515.42 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 9 9 5276.71 $65958.93 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 133.57 $3339.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 127 168 2680.79 $134039.61 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 26.43 $1321.43 $50.00
INTR -INTR INTERPRETER 8 9 23.18 $1158.93 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 56 76 1157.21 $78551.75 $67.88
OCCT -97530HM OT SESSION BY OT ASST 24 26 469.14 $25483.51 $54.32
PHY -97110 PT SESSION BY LICENSED PT 44 61 1015.34 $68921.06 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 22 281.44 $15287.95 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 15.00 $15.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.50 $75.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 104 1984.43 $134703.03 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 25.43 $1381.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 32 36 719.35 $9495.45 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 35.00 $3500.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 67.68 $3384.06 $50.00
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Subtotal (Total Children Is Unduplicated) 289 662 14206.30 $574178.02 $40.42
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Total 1302 15125.54 $634387.55 $41.94
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Number of Children (Unduplicated) With at Least One Authorization 377