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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 30 30 67.00 $3350.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 4 8.00 $444.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 14.00 $777.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 45 45 90.00 $6750.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 22.00 $1650.00 $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 57 57 114.00 $6327.00 $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 12 15.00 $727.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 18.00 $873.00 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 126 228 437.00 $27350.98 $62.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 14.00 $21000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 4.79 $239.29 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 80 146 287.00 $14350.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 69 72 144.80 $7240.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 37 73.80 $3690.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.00 $75.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 50 99.80 $4990.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 69 136.80 $6840.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 18.00 $450.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 67.64 $1691.07 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 8 9 59.36 $2967.87 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.57 $64.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 71 73 485.93 $24296.66 $50.00
INTR -INTR INTERPRETER 7 7 9.00 $450.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 14 14 50.71 $3442.48 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.71 $147.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 31 32 124.41 $8444.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 4.98 $270.31 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 17.00 $17.00 $1.00
SENS -V5264 EARMOLD 1 1 0.14 $2.70 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 57 238.07 $16160.27 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 21.69 $286.31 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 9.14 $914.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 117 145 2141.40 $1070.70 $0.50
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Subtotal (Total Children Is Unduplicated) 181 754 4020.75 $119200.58 $29.65
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Total 982 4457.75 $146551.56 $32.88
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Number of Children (Unduplicated) With at Least One Authorization 216