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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 0.48 $28.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 29 29 54.00 $2700.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $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 10 10 20.00 $1110.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 49 50 100.00 $7500.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 10 20.00 $1500.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 32 33 66.00 $4950.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 57 57 114.00 $6327.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 14.00 $1050.00 $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 10 10 10.00 $485.00 $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 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 13 13 13.00 $630.50 $48.50
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Subtotal (Total Children Is Unduplicated) 119 228 421.48 $26831.47 $63.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 13 17.00 $25500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.07 $153.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 143 281 564.07 $28203.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 130 136 274.13 $13706.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 64 67 132.00 $6600.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 83 91 181.00 $9050.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 120 243.20 $12160.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.00 $100.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 94.44 $2360.95 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 22.57 $1128.58 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 118 122 700.74 $35036.93 $50.00
INTR -INTR INTERPRETER 4 5 10.00 $500.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 33 35 148.35 $10069.83 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $58.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 58 211.64 $14366.13 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 7.50 $407.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.40 $5.40 $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 1.91 $35.78 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 82 366.06 $24848.28 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 35.36 $466.72 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 170 229 1204.06 $602.03 $0.50
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Subtotal (Total Children Is Unduplicated) 195 1274 4228.57 $185859.78 $43.95
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Total 1502 4650.04 $212691.25 $45.74
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Number of Children (Unduplicated) With at Least One Authorization 213