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
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
EXIT -EXIT TRANSITION ASSESSMENT 4 5 8.00 $400.00 $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 3 3 6.00 $333.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 83 83 147.55 $11066.25 $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 88 88 154.55 $8577.53 $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 79 92 92.00 $4462.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 30 30 30.00 $1455.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 79 90 90.00 $4365.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 49 49 49.00 $2376.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 261 293 293.00 $14210.50 $48.50
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Subtotal (Total Children Is Unduplicated) 398 794 973.60 $55250.88 $56.75
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 180 203 276.00 $13800.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 7 7.00 $175.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 146 153 247.92 $12396.23 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 2.30 $57.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 64 94.16 $4708.24 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 70 77 123.48 $6174.03 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 151 162 245.76 $12287.94 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 201 1275.08 $63754.04 $50.00
INTR -INTR INTERPRETER 7 11 38.30 $1914.76 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 104 123 883.19 $59950.60 $67.88
PHY -97110 PT SESSION BY LICENSED PT 128 147 1145.89 $77783.18 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 65 65 65.00 $65.00 $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 283 332 2087.73 $141715.23 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.93 $746.43 $50.00
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Subtotal (Total Children Is Unduplicated) 528 1557 6523.74 $398638.09 $61.11
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Total 2351 7497.34 $453888.96 $60.54
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Number of Children (Unduplicated) With at Least One Authorization 557