Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 7 7 10.00 $500.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 5 5 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 29 29 32.00 $2400.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 10.00 $750.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 20 20 21.00 $1575.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 37 37 43.00 $3225.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.00 $436.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 9.00 $436.50 $48.50
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Subtotal (Total Children Is Unduplicated) 70 139 153.00 $10364.00 $67.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.10 $55.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 146 306 612.00 $30600.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 123 137 274.00 $13700.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 65 130.00 $6500.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 74 76 152.00 $7600.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 98 104 208.00 $10400.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.60 $40.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 16 29.55 $738.63 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 10 60.86 $3042.85 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 106 120 736.56 $36827.89 $50.00
INTR -INTR INTERPRETER 5 5 10.00 $500.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 47 237.16 $16098.72 $67.88
PHY -97110 PT SESSION BY LICENSED PT 65 66 249.06 $16906.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.71 $364.72 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.37 $6.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 82 88 416.11 $28245.50 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.86 $143.31 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 164 218 446.43 $223.21 $0.50
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Subtotal (Total Children Is Unduplicated) 181 1275 3596.36 $190593.02 $53.00
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Total 1414 3749.36 $200957.02 $53.60
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Number of Children (Unduplicated) With at Least One Authorization 182