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: 10/01/08 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
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.07 $155.36 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $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 2 2 2.50 $138.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 36.00 $2700.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 4.50 $337.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 30.00 $1665.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 13.00 $975.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 30 32 32.00 $1552.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 21.00 $1018.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 33 36 36.00 $1746.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 20 20 20.00 $970.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 89 96 96.00 $4656.00 $48.50
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Subtotal (Total Children Is Unduplicated) 171 266 302.64 $16721.16 $55.25
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 72 85 115.05 $5752.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 79 85 143.02 $7151.03 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 26 45.03 $2251.52 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 27 36.21 $1810.55 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 81 136.19 $6809.34 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 111 118 723.17 $36158.58 $50.00
INTR -INTR INTERPRETER 5 5 61.86 $3092.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 52 56 381.66 $25907.10 $67.88
PHY -97110 PT SESSION BY LICENSED PT 53 58 428.59 $29092.40 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 12.91 $12.91 $1.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 2 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 99 548.89 $37258.71 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.14 $107.15 $50.00
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Subtotal (Total Children Is Unduplicated) 234 660 2643.72 $156206.89 $59.09
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Total 926 2946.36 $172928.05 $58.69
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Number of Children (Unduplicated) With at Least One Authorization 262