Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 11 12.00 $582.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 16 15.23 $914.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 26 26 43.04 $2151.79 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 11.50 $862.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 19.50 $1082.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 140 140 193.00 $14475.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 11.00 $825.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 47 48 82.14 $6160.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 166 166 227.86 $12646.07 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 141 145 198.36 $14876.79 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 17.14 $831.43 $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 7 7 16.14 $782.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 20.14 $976.93 $48.50
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Subtotal (Total Children Is Unduplicated) 338 617 877.06 $57953.61 $66.08
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 29 30.00 $45000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.00 $200.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 30 36.64 $1832.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 13 11.88 $297.08 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 10.50 $525.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 10.80 $270.12 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 7.23 $361.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 3.57 $89.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 4.47 $223.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 9.59 $239.76 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 22 156.00 $3900.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 160 168 924.89 $46244.54 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 0.14 $7.15 $50.00
INTR -INTR INTERPRETER 11 11 55.04 $2751.79 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 49 57 335.58 $22779.26 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 58.71 $3189.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 95 105 592.33 $40207.63 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 9 63.11 $3428.11 $54.32
RSPT -RSPT RESPITE 1 1 49.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 163.03 $163.03 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 246 264 1581.35 $107342.24 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 140.64 $1856.48 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 4.29 $428.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 373 509 2489.95 $1244.98 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 31.57 $1578.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 14.86 $742.86 $50.00
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Subtotal (Total Children Is Unduplicated) 491 1303 6790.25 $284921.54 $41.96
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Total 1920 7667.31 $342875.15 $44.72
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Number of Children (Unduplicated) With at Least One Authorization 689