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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.26 $75.34 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 9 9 17.00 $850.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $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 2 2 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 16.00 $888.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 39 39 75.00 $5625.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 18.00 $1350.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 25 25 47.00 $3525.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 34 34 68.00 $3774.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 17 29.00 $2175.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 14 14.00 $679.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 18 18.00 $873.00 $48.50
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Subtotal (Total Children Is Unduplicated) 92 187 320.26 $20931.84 $65.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 11.00 $16500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.64 $82.15 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 107 231 462.00 $23100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 113 114 229.47 $11473.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 54 108.00 $5400.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 68 69 138.00 $6900.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 95 97 194.00 $9700.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.10 $52.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 14 32.67 $816.78 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 7 65.71 $3285.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 94 668.67 $33433.60 $50.00
INTR -INTR INTERPRETER 4 5 9.00 $450.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 22 23 98.25 $6669.54 $67.88
PHY -97110 PT SESSION BY LICENSED PT 58 59 244.41 $16590.37 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 6.00 $6.00 $1.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.04 $2.67 $65.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 58 270.78 $18380.28 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.21 $2.83 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 12.71 $1271.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 139 181 789.78 $394.89 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 4.00 $200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 156 1027 3348.46 $154712.09 $46.20
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Total 1214 3668.71 $175643.93 $47.88
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Number of Children (Unduplicated) With at Least One Authorization 168