Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 01/01/10 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
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 74.86 $5614.28 $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 1 1 2.00 $111.00 $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 32 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 50 50.00 $2425.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 29 31 31.00 $1503.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 107 119 119.00 $5771.50 $48.50
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Subtotal (Total Children Is Unduplicated) 211 325 376.86 $21149.78 $56.12
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 137 147 207.22 $10360.87 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 69 119.12 $5956.15 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 64 120.33 $6016.58 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 122 152.51 $7625.52 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.80 $45.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 160 172 1045.48 $52273.96 $50.00
INTR -INTR INTERPRETER 11 11 184.92 $9245.99 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 46 56 399.00 $27084.13 $67.88
PHY -97110 PT SESSION BY LICENSED PT 71 81 595.89 $40449.05 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 54 54 54.00 $54.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 105 118 799.29 $54255.55 $67.88
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Subtotal (Total Children Is Unduplicated) 329 1044 3858.56 $223666.77 $57.97
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Total 1369 4235.41 $244816.56 $57.80
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Number of Children (Unduplicated) With at Least One Authorization 345