Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 10.126984 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.005479 $0.2000 $37.1400
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Subtotal (Total Children Is Unduplicated) 9 9 10.132463 $0.2000 $0.0200
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.224658 $13.4800 $60.0100
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.009589 $0.4800 $50.0600
EXIT -EXIT EXIT ASSESSMENT 24 25 16.832963 $841.6500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.008333 $0.6200 $74.7000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 0.036034 $2.7000 $74.9300
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 0.016437 $1.2400 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.016590 $1.2500 $75.0500
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 0.041360 $2.3000 $55.5500
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 86 86 7.157062 $536.7700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 28 28 6.155742 $461.6900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 42 42 9.267724 $514.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 55 56 3.903374 $292.7600 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.516667 $25.0600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 0.350000 $16.9800 $48.5000
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Subtotal (Total Children Is Unduplicated) 143 261 44.536533 $2711.3300 $60.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.800000 $2700.0000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 0.130254 $6.5100 $49.9400
CONIF -CONIF CONSULT ITDS, FACE TO FACE 23 28 43.385713 $2169.2800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 27 36.188095 $1809.4000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.700001 $285.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 32 53.596034 $2679.8100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.971429 $74.2900 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 93.571430 $1169.6400 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 115.000001 $2875.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 97 101 604.628579 $30231.4300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.700000 $35.0000 $50.0000
INTR -INTR INTERPRETER 13 16 1.236244 $61.8100 $49.9900
OCCT -97530 OT SESSION BY LICENSED OT 26 28 146.785715 $9963.7900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.714286 $473.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 20 20 111.747621 $7585.4400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 21.552381 $1170.7300 $54.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 32 215.500001 $14628.1600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 2 4.285714 $56.5700 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.671429 $633.5700 $50.0000
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Subtotal (Total Children Is Unduplicated) 170 323 1480.164927 $78608.7800 $53.1100
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Total 593 1534.833923 $81320.3100 $52.9800
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Number of Children (Unduplicated) With at Least One Authorization 228