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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 10 12.31 $738.67 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.00 $150.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 32 38 61.00 $3050.00 $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 7 7 9.00 $675.00 $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 3 3 5.00 $375.00 $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 36 36 44.00 $2442.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 146 148 202.00 $15150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 47 47 59.00 $4425.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 98 99 126.00 $9450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 97 98 146.00 $8103.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 106 107 130.00 $9750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 57 63 63.00 $3055.50 $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 24 24 24.00 $1164.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 49 60 60.00 $2910.00 $48.50
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Subtotal (Total Children Is Unduplicated) 324 754 958.31 $62247.17 $64.96
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 31 42 59.00 $88500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 5 31.48 $1574.05 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 347 1209 2417.00 $120850.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 332 514 1040.75 $52037.62 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 172 254 508.00 $25400.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 198 296 592.00 $29600.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 272 402 826.00 $41300.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 13 13 55.17 $1379.16 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 54 208.55 $5213.63 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 41 49 904.14 $45207.16 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 271 424 6493.30 $324664.81 $50.00
INTR -INTR INTERPRETER 12 18 56.86 $2842.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 98 149 1865.70 $126643.87 $67.88
PHY -97110 PT SESSION BY LICENSED PT 165 251 2560.16 $173783.69 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.29 $721.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 7.00 $7.00 $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 2 0.55 $35.44 $65.00
SENS -V5264 EARMOLD 3 4 11.90 $222.77 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 216 303 3487.22 $236712.60 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 58.07 $766.54 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 4 15.71 $1571.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 407 868 2247.07 $1123.53 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 17.07 $853.57 $50.00
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Subtotal (Total Children Is Unduplicated) 431 4877 23479.98 $1282061.41 $54.60
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Total 5631 24438.29 $1344308.58 $55.01
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Number of Children (Unduplicated) With at Least One Authorization 437