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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 1.09 $65.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 19 19 44.00 $2200.00 $50.00
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 31 31 62.00 $4650.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 19 19 38.00 $2850.00 $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 4 4 8.00 $600.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 13 30.86 $1496.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 6.00 $291.00 $48.50
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Subtotal (Total Children Is Unduplicated) 81 144 284.95 $17413.70 $61.11
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 13.00 $19500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 10.50 $525.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 82 143 290.50 $14525.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 62 68 139.00 $6950.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 33 67.00 $3350.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 49 98.50 $4925.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 60 120.00 $6000.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 29.57 $739.29 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 32.43 $1621.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 53 55 327.96 $16398.12 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 13 13 85.95 $5834.12 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 10.43 $566.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 32 32 146.59 $9950.23 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 18 24.00 $24.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 0.16 $2.91 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 39 234.58 $15923.34 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 95 137 1803.83 $901.92 $0.50
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Subtotal (Total Children Is Unduplicated) 150 673 3440.99 $108986.82 $31.67
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Total 817 3725.94 $126400.52 $33.92
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Number of Children (Unduplicated) With at Least One Authorization 171