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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 10 10 6.078570 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 6.078570 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.324505 $15.7400 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.183333 $11.0000 $59.9900
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 0.007534 $0.3800 $49.7700
EXIT -EXIT EXIT ASSESSMENT 26 26 12.621003 $631.0500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 0.038812 $2.9100 $74.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.016590 $1.2500 $75.0500
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 3 3 0.022069 $1.2300 $55.5700
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 81 81 0.597890 $44.8500 $75.0100
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 0.120813 $9.0700 $75.0500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 49 49 0.292989 $16.2800 $55.5700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 42 42 0.292686 $21.9500 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.638889 $30.9900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 0.344444 $16.7000 $48.4900
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.055556 $2.7800 $50.0400
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Subtotal (Total Children Is Unduplicated) 139 242 15.573703 $807.4100 $51.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.566666 $22833.0000 $4999.9300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 28 30 0.119183 $5.9400 $49.8400
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 35 48.641631 $2432.0900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 29 46.842859 $2342.1500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 7.204762 $360.2400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 30 44.500001 $2225.0100 $50.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 8 8 796.857142 $9960.7100 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 80.714285 $2017.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 111 118 680.904760 $34045.2500 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 5.533333 $276.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.733333 $36.6700 $50.0000
INTR -INTR INTERPRETER 6 8 4.859360 $242.9700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 45 220.385712 $14959.7700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 31 31 157.471423 $10689.1500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 4.861904 $264.1000 $54.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 39 221.404761 $15028.9500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 10.214286 $134.8300 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 8.142857 $407.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 185 394 2343.958258 $118262.4800 $50.4500
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Total 646 2365.610531 $119069.8900 $50.3300
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Number of Children (Unduplicated) With at Least One Authorization 298