Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 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 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 10 16 25.00 $1250.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 3.00 $166.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 8 8 8.00 $444.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 31 31 36.00 $2700.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 9.00 $675.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 17 17 18.00 $1350.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 37 37 42.00 $3150.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 12.00 $582.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 11.00 $533.50 $48.50
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Subtotal (Total Children Is Unduplicated) 78 154 177.00 $11607.50 $65.58
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 10.00 $15000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.97 $98.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 116 296 592.00 $29600.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 115 122 244.00 $12200.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 59 118.00 $5900.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 64 128.00 $6400.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 88 95 190.00 $9500.00 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 17 22.49 $562.20 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 41.29 $2064.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 106 116 735.56 $36777.84 $50.00
INTR -INTR INTERPRETER 5 5 18.71 $935.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 37 37 231.30 $15700.48 $67.88
PHY -97110 PT SESSION BY LICENSED PT 50 51 227.89 $15469.50 $67.88
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.66 $12.27 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 73 330.55 $22437.54 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 13.14 $173.49 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 136 208 415.43 $207.71 $0.50
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Subtotal (Total Children Is Unduplicated) 153 1159 3321.98 $173539.37 $52.24
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Total 1313 3498.98 $185146.87 $52.91
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Number of Children (Unduplicated) With at Least One Authorization 157