Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 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 136 149 183.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 136 149 183.00 $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 81 139 164.71 $7988.64 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 79 81 81.00 $3928.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 97 148 154.43 $7489.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 78 79 79.00 $3831.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 273 394 395.00 $19157.50 $48.50
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Subtotal (Total Children Is Unduplicated) 412 986 1113.79 $58638.29 $52.65
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.09 $154.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 134 165 228.05 $11402.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 210 324 1351.32 $67566.03 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 107 509.54 $25476.95 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 77 102 446.09 $22304.25 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.30 $57.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 213 304 1166.46 $58323.11 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 319 502 7151.41 $357570.34 $50.00
INTR -INTR INTERPRETER 23 43 268.77 $13438.31 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 127 218 2872.62 $194993.25 $67.88
PHY -97110 PT SESSION BY LICENSED PT 147 235 3538.01 $240160.41 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 42 45.99 $45.99 $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 7 11.00 $205.92 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 278 411 5371.18 $364595.52 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 79.49 $3974.60 $50.00
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Subtotal (Total Children Is Unduplicated) 562 2476 23055.31 $1362808.66 $59.11
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Total 3611 24352.10 $1421446.95 $58.37
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Number of Children (Unduplicated) With at Least One Authorization 574