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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
EXIT -EXIT TRANSITION ASSESSMENT 2 2 4.00 $200.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 13 13 19.00 $1425.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 15.00 $1125.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 38 38 66.50 $3690.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 6.50 $487.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 29 33 33.00 $1600.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.00 $388.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 32 36 36.00 $1746.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 24 24.00 $1164.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 93 98 98.00 $4753.00 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 163 305 379.50 $21778.45 $57.39
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 80 87 126.00 $6300.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 78 82 125.15 $6257.51 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 23 38.72 $1935.84 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 36 56.85 $2842.27 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 74 78 119.33 $5966.27 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 98 104 627.27 $31363.34 $50.00
INTR -INTR INTERPRETER 5 9 34.30 $1714.76 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 43 311.29 $21130.08 $67.88
PHY -97110 PT SESSION BY LICENSED PT 57 63 481.14 $32659.96 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 39 39 39.00 $39.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 102 112 636.14 $43181.35 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.93 $746.43 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 244 683 2617.10 $156198.48 $59.68
-----------------------------------------------------------------------------------------------------------------------------
Total 988 2996.60 $177976.93 $59.39
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 258