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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 12 13 23.00 $1150.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.00 $111.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 18.00 $999.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 46 46 92.00 $6900.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 13 13 26.00 $1950.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 31 31 62.00 $4650.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 55 55 110.00 $6105.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.00 $450.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 19 20 21.53 $1044.37 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 104 209 382.53 $24610.87 $64.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 9.00 $13500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.10 $55.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 96 192 384.00 $19200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 105 112 224.73 $11236.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 49 98.00 $4900.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 65 130.00 $6500.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 88 94 188.00 $9400.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 1.60 $40.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 14 21.92 $548.07 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 38.71 $1935.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 92 98 542.65 $27132.40 $50.00
INTR -INTR INTERPRETER 4 4 6.43 $321.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 24 26 76.30 $5179.07 $67.88
PHY -97110 PT SESSION BY LICENSED PT 52 57 196.72 $13353.44 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.37 $6.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 57 206.53 $14018.99 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 1 1 12.57 $1257.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 164 199 541.26 $270.63 $0.50
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Subtotal (Total Children Is Unduplicated) 184 987 2681.89 $129356.42 $48.23
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Total 1196 3064.42 $153967.28 $50.24
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Number of Children (Unduplicated) With at Least One Authorization 199