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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 3.00 $0.00 $0.00
TCON -TCON TRANSITION CONFERENCE 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 4 5 5.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 16 16 31.00 $1550.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.50 $487.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 59 59 102.50 $7687.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 36 65.50 $4912.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 16.00 $1200.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 64 64 112.07 $6219.70 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 18 34.00 $2550.00 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 122 224 387.07 $25745.45 $66.51
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 13.75 $687.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.27 $56.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 10 12 10.50 $525.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 12.23 $611.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 9.97 $498.34 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 80.71 $2017.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 69 366.02 $18300.96 $50.00
INTR -INTR INTERPRETER 11 18 24.50 $1225.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 28 30 151.88 $10309.38 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 13.03 $707.97 $54.32
PHY -97110 PT SESSION BY LICENSED PT 12 12 74.28 $5042.18 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.14 $7.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 27 170.50 $11573.55 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 27.30 $360.42 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 6.71 $335.72 $50.00
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Subtotal (Total Children Is Unduplicated) 134 231 974.80 $55488.95 $56.92
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Total 460 1366.87 $81234.41 $59.43
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Number of Children (Unduplicated) With at Least One Authorization 231