Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 4.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 3 3 4.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 21.50 $1612.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 20 21 37.50 $2812.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 57.00 $3163.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.00 $300.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 19 28.00 $1358.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 22.00 $1067.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 32 32 32.00 $1552.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 22.00 $1067.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 84 89 89.00 $4316.50 $48.50
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Subtotal (Total Children Is Unduplicated) 158 256 322.00 $17929.60 $55.68
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 59 64 88.07 $4403.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 67 71 142.03 $7101.25 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 24 48.89 $2444.65 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 22 39.91 $1995.49 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 71 75 137.30 $6864.95 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 105 113 684.12 $34206.23 $50.00
INTR -INTR INTERPRETER 7 7 52.36 $2617.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 41 41 280.08 $19011.56 $67.88
PHY -97110 PT SESSION BY LICENSED PT 54 55 360.68 $24483.03 $67.88
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 86 92 538.11 $36526.88 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 13.76 $688.02 $50.00
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Subtotal (Total Children Is Unduplicated) 205 570 2389.30 $140430.67 $58.77
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Total 829 2715.30 $158360.27 $58.32
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Number of Children (Unduplicated) With at Least One Authorization 240