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: 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
EXIT -EXIT TRANSITION ASSESSMENT 37 38 76.00 $3800.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 43 43 82.50 $6187.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 32 54.50 $4087.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 12.03 $902.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 29 30 50.03 $2776.85 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 29 54.00 $4050.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.00 $242.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 8.41 $840.96 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 120 194 351.48 $23392.81 $66.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.50 $275.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 7.00 $350.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.93 $73.22 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 9.13 $456.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 11.00 $550.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 350.29 $4378.57 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 10.71 $267.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 69 383.81 $19190.47 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 8.14 $407.15 $50.00
INTR -INTR INTERPRETER 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 19 20 106.50 $7228.91 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 30.71 $1668.41 $54.32
PHY -97110 PT SESSION BY LICENSED PT 12 12 64.36 $4368.56 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 23 145.57 $9881.39 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 13.03 $172.04 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 19.29 $964.29 $50.00
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Subtotal (Total Children Is Unduplicated) 124 183 1179.97 $51986.53 $44.06
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Total 377 1531.45 $75379.34 $49.22
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Number of Children (Unduplicated) With at Least One Authorization 210