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: 01/01/08 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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 8 11.06 $663.34 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 10.00 $500.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 24 29 45.00 $2250.00 $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 6 6 8.00 $600.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 10.00 $555.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 30 30 32.00 $1776.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 133 134 171.00 $12825.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 43 43 50.00 $3750.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 89 90 106.00 $7950.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 86 86 117.00 $6493.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 104 105 126.00 $9450.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 56 56.00 $2716.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 35 35.00 $1697.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 51 57 57.00 $2764.50 $48.50
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Subtotal (Total Children Is Unduplicated) 320 706 846.06 $54779.41 $64.75
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 46 62.00 $93000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 25.90 $1295.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 329 1009 2039.86 $101992.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 329 543 1127.14 $56357.14 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 163 267 533.00 $26650.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 198 313 625.00 $31250.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 268 410 841.00 $42050.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 11 11 50.23 $1255.83 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 12 12 23.12 $577.98 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 38 167.82 $4195.53 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 44 57 936.71 $46835.71 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 84 84 553.13 $27656.68 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 244 356 5951.45 $297572.66 $50.00
INTR -INTR INTERPRETER 16 22 51.07 $2553.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 110 182 2091.64 $141980.70 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.36 $19.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 168 272 2735.32 $185673.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.29 $721.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 2 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.50 $32.77 $65.00
SENS -V5264 EARMOLD 3 4 10.59 $198.22 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 225 341 3810.69 $258669.67 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 87.93 $1160.66 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 4 7.13 $713.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 436 897 1900.86 $950.43 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 58.21 $2910.72 $50.00
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Subtotal (Total Children Is Unduplicated) 473 4889 23708.97 $1327324.96 $55.98
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Total 5595 24555.02 $1382104.37 $56.29
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Number of Children (Unduplicated) With at Least One Authorization 485