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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 3 3 6.00 $717.60 $119.60
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 3 3 6.00 $333.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 85 85 167.55 $12566.25 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 26 26 42.00 $3150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 19 19 33.50 $2512.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 90 90 174.55 $9687.53 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 16.00 $1200.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 69 77 84.43 $4094.79 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 45 45 45.00 $2182.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 75 83 83.00 $4025.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 38 38 38.00 $1843.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 223 244 244.00 $11834.00 $48.50
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Subtotal (Total Children Is Unduplicated) 441 726 946.03 $54571.66 $57.69
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.94 $96.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 178 201 273.00 $13650.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 7 7.00 $175.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 132 139 221.95 $11097.39 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 55 87.49 $4374.40 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 60 101.34 $5067.08 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 125 133 192.98 $9649.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 190 207 1265.02 $63251.13 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.64 $232.15 $50.00
INTR -INTR INTERPRETER 8 12 39.93 $1996.55 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 105 116 708.37 $48083.84 $67.88
PHY -97110 PT SESSION BY LICENSED PT 107 119 775.79 $52660.35 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 43 43 41.81 $41.81 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 6.00 $1422.72 $237.12
SENS -V5264 EARMOLD 5 5 10.00 $187.20 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 231 266 1455.39 $98791.66 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 5.07 $253.57 $50.00
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Subtotal (Total Children Is Unduplicated) 475 1370 5197.72 $311030.98 $59.84
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Total 2096 6143.75 $365602.64 $59.51
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Number of Children (Unduplicated) With at Least One Authorization 604