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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 30 30 60.00 $3000.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 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 38 38 70.57 $5292.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 42.50 $3187.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 55.53 $3082.10 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 38.00 $2850.00 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 2.90 $140.65 $48.50
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Subtotal (Total Children Is Unduplicated) 95 156 286.50 $18762.25 $65.49
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.00 $50.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 5.50 $275.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 9 10 8.75 $437.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.27 $163.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.25 $31.25 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.27 $6.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 9.60 $480.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.27 $6.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 19.29 $241.07 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.57 $214.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 76 83 551.23 $27561.67 $50.00
INTR -INTR INTERPRETER 4 5 10.29 $514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 18 18 67.33 $4570.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.07 $329.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 20 20 150.75 $10232.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 12.57 $682.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.00 $8.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 28 211.19 $14335.26 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.26 $148.59 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.29 $14.29 $50.00
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Subtotal (Total Children Is Unduplicated) 136 207 1088.73 $63303.74 $58.14
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Total 363 1375.23 $82065.99 $59.67
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Number of Children (Unduplicated) With at Least One Authorization 205