Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 Page: 1
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 -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 20 28 44.00 $2200.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.00 $225.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 26 26 28.00 $1554.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 102 102 117.00 $8775.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 26.00 $1950.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 38 38 45.00 $3375.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 8.00 $444.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 101 101 117.50 $8812.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 23 23.00 $1115.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 17.00 $824.50 $48.50
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Subtotal (Total Children Is Unduplicated) 193 383 446.50 $30221.50 $67.69
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 28 35.00 $52500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 8.82 $441.19 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 285 740 1550.14 $77507.14 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 264 284 567.00 $28350.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 130 140 342.86 $17142.86 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 126 135 270.00 $13500.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 217 230 478.57 $23928.57 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 43 72.75 $1818.86 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 9 9 57.71 $2885.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 235 265 1579.35 $78967.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.57 $128.57 $50.00
INTR -INTR INTERPRETER 5 5 18.71 $935.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 86 91 464.37 $31521.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.29 $178.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 97 102 466.69 $31678.60 $67.88
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.66 $12.27 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 181 200 918.04 $62316.41 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 13.14 $173.49 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 305 498 1014.62 $507.31 $0.50
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Subtotal (Total Children Is Unduplicated) 354 2779 7867.30 $425044.27 $54.03
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Total 3162 8313.80 $455265.77 $54.76
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Number of Children (Unduplicated) With at Least One Authorization 363