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: 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 24 26 26.00 $1261.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 13 13.00 $630.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 24 25 31.43 $1524.29 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 71 72.00 $3492.00 $48.50
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Subtotal (Total Children Is Unduplicated) 119 207 251.07 $14219.95 $56.64
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 69 83 113.29 $5664.29 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 61 69 114.54 $5727.04 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 19 31.47 $1573.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 23 51.90 $2595.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.30 $57.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 65 103.38 $5168.97 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 91 99 619.75 $30987.65 $50.00
INTR -INTR INTERPRETER 5 5 27.72 $1385.84 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 41 252.92 $17168.11 $67.88
PHY -97110 PT SESSION BY LICENSED PT 36 38 277.45 $18833.46 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 30 29.19 $29.19 $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 71 75 459.36 $31181.19 $67.88
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Subtotal (Total Children Is Unduplicated) 200 553 2092.26 $121173.67 $57.92
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Total 760 2343.33 $135393.62 $57.78
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Number of Children (Unduplicated) With at Least One Authorization 206