Summary Report for FSPSAs Ending During the Report Period Center: 03
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
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 40 40 74.36 $5576.78 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 17.50 $1312.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 9.50 $712.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 34 41 41.00 $1988.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 24 24.00 $1164.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 42 46 46.00 $2231.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 25 33.71 $1635.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 102 115 115.00 $5577.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 220 310 370.57 $20842.18 $56.24
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 123 141 174.00 $8700.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 116 128 141.60 $7080.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 62 71.57 $3578.42 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 49 54.80 $2739.79 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 101 110 115.50 $5775.12 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 137 148 835.73 $41786.46 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.33 $16.67 $50.00
INTR -INTR INTERPRETER 10 10 74.18 $3708.92 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 51 62 360.43 $24465.87 $67.88
PHY -97110 PT SESSION BY LICENSED PT 62 68 351.41 $23853.99 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 64 65 65.00 $65.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 114 618.36 $41974.09 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.57 $628.57 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 325 964 2880.48 $165973.05 $57.62
-----------------------------------------------------------------------------------------------------------------------------
Total 1274 3251.05 $186815.22 $57.46
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 379