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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT TRANSITION ASSESSMENT 32 32 64.000000 $3200.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.500000 $262.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 7.000000 $525.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 5 7.500000 $416.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 50 50 86.000000 $6450.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 38 62.000000 $4650.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 2.500000 $187.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 24 24 39.000000 $2164.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 41 41 72.033333 $5402.5000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 121 209 358.533333 $24227.2500 $67.5700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.000000 $100.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 15.502740 $775.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 3.071429 $76.7900 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 15 15.783333 $789.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 16.316667 $815.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 12.419047 $620.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.000000 $50.0000 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 52.142857 $651.7900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 224.428571 $5610.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 71 76 388.204765 $19410.2400 $50.0000
INTR -INTR INTERPRETER 10 13 15.000000 $750.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 151.471430 $10281.8700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 6 6 22.142856 $1202.8100 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 21 21 77.266669 $5244.8600 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.000000 $4.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 31 198.571428 $13479.0400 $67.8800
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 3.857143 $192.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 151 258 1204.178935 $60056.0400 $49.8700
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Total 467 1562.712268 $84283.2800 $53.9300
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Number of Children (Unduplicated) With at Least One Authorization 238