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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 1 1 2.00 $150.00 $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 31 31 50.50 $3787.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 26.50 $1987.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 54.00 $2997.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 10.50 $787.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 34 37 37.00 $1794.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 13.00 $630.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 32 34 38.57 $1870.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 22.00 $1067.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 90 100 101.00 $4898.50 $48.50
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Subtotal (Total Children Is Unduplicated) 178 296 361.07 $20431.91 $56.59
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 104 112 158.00 $7900.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 76 84 120.73 $6036.69 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 28 43.98 $2198.88 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 34 54.76 $2737.78 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.80 $20.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 81 120.50 $6024.79 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 105 121 727.74 $36387.17 $50.00
INTR -INTR INTERPRETER 8 9 73.47 $3673.45 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 47 307.24 $20855.63 $67.88
PHY -97110 PT SESSION BY LICENSED PT 53 57 358.32 $24322.70 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 43 43.00 $43.00 $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 93 104 689.60 $46810.02 $67.88
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Subtotal (Total Children Is Unduplicated) 245 726 2705.14 $159071.78 $58.80
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Total 1022 3066.21 $179503.69 $58.54
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Number of Children (Unduplicated) With at Least One Authorization 291