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
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 2 2 4.00 $478.40 $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 37 37 64.50 $4837.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 11.50 $862.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 37 37 63.50 $3524.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 12 21.50 $1612.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 63 65 65.00 $3152.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 33 33.00 $1600.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 61 68 74.43 $3609.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 27 28 28.00 $1358.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 174 185 186.00 $9021.00 $48.50
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Subtotal (Total Children Is Unduplicated) 272 485 566.57 $31143.90 $54.97
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 162 186 237.57 $11878.57 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 16 20.00 $500.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 124 132 240.98 $12048.90 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 44 76.97 $3848.29 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 48 98.22 $4910.91 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.30 $57.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 128 216.26 $10813.05 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 188 1328.40 $66420.06 $50.00
INTR -INTR INTERPRETER 6 6 29.72 $1485.84 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 86 97 696.61 $47286.17 $67.88
PHY -97110 PT SESSION BY LICENSED PT 94 109 769.67 $52244.98 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 49 49 47.38 $47.38 $1.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 3 3 6.00 $112.32 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 198 1394.41 $94652.59 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 9.86 $492.86 $50.00
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Subtotal (Total Children Is Unduplicated) 425 1210 5182.34 $310975.86 $60.01
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Total 1695 5748.91 $342119.75 $59.51
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Number of Children (Unduplicated) With at Least One Authorization 436