Summary Report for FSPSAs Initiated During the Report Period Center: 05
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
EXIT -EXIT TRANSITION ASSESSMENT 35 35 88.00 $4400.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 4 8.00 $444.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 10 10 20.00 $1110.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 50 50 100.00 $7500.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 21.00 $1575.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 30 30 60.00 $4500.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 56 56 111.00 $6160.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 18.00 $1350.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 11 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 15 26.57 $1288.71 $48.50
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Subtotal (Total Children Is Unduplicated) 130 238 475.57 $29602.71 $62.25
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 140 280.00 $14000.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 81 83 166.00 $8300.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 36 71.00 $3550.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 43 86.00 $4300.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 74 149.00 $7450.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 17.00 $425.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 26.86 $671.43 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 15 82.04 $4102.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.40 $60.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 77 437.31 $21865.51 $50.00
INTR -INTR INTERPRETER 5 6 19.86 $992.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 17 18 104.70 $7107.04 $67.88
PHY -97110 PT SESSION BY LICENSED PT 25 26 133.42 $9056.33 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 14.00 $14.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 62 389.94 $26469.17 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 14.14 $186.69 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 114 165 7337.69 $3668.84 $0.50
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Subtotal (Total Children Is Unduplicated) 180 782 9345.36 $124619.01 $13.33
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Total 1020 9820.93 $154221.72 $15.70
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Number of Children (Unduplicated) With at Least One Authorization 215