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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 138 152 187.60 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 138 152 187.60 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.07 $230.36 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.57 $42.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.50 $360.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 33 33 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 41.50 $3112.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 14.00 $1050.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 50 50 85.00 $4717.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 20.50 $1537.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 87 151 159.54 $7737.64 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 72 72 72.00 $3492.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 109 170 170.00 $8245.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 85 88 88.00 $4268.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 262 401 401.00 $19448.50 $48.50
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Subtotal (Total Children Is Unduplicated) 433 1027 1130.18 $59433.50 $52.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 132 162 222.05 $11102.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 177 290 1277.71 $63885.55 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 87 441.48 $22073.81 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 86 386.16 $19308.18 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 178 268 1050.82 $52541.10 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 70 71 417.48 $20873.82 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 261 436 6368.79 $318439.38 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.40 $120.00 $50.00
INTR -INTR INTERPRETER 26 46 287.05 $14352.71 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 132 224 2887.78 $196022.65 $67.88
PHY -97110 PT SESSION BY LICENSED PT 164 270 3621.20 $245807.38 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 15.52 $15.52 $1.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 6 9.00 $168.48 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 258 408 5061.41 $343568.57 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 139.35 $6967.46 $50.00
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Subtotal (Total Children Is Unduplicated) 529 2386 22198.21 $1317786.56 $59.36
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Total 3565 23515.99 $1377220.06 $58.57
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Number of Children (Unduplicated) With at Least One Authorization 583