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: 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 1 1 2.00 $239.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 31 32 60.00 $3000.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 4.00 $222.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.00 $600.00 $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 2.00 $150.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 17 17 34.00 $1887.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 82 82 164.00 $12300.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 42.00 $3150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 41 82.00 $6150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 92 92 184.00 $10212.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.00 $150.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 25 26.00 $1261.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 29 31 33.00 $1600.50 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 192 366 664.00 $42280.20 $63.68
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 30 80.00 $120000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 11.43 $571.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 249 526 1051.00 $52550.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.50 $12.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 251 258 515.00 $25750.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 105 109 218.00 $10900.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 142 146 296.20 $14810.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 212 223 447.60 $22380.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 5.47 $136.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 36 78.40 $1960.01 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 12 12 67.00 $3350.01 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 212 220 1293.78 $64689.15 $50.00
INTR -INTR INTERPRETER 4 4 16.00 $800.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 68 72 300.99 $20431.39 $67.88
PHY -97110 PT SESSION BY LICENSED PT 104 108 490.72 $33310.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.64 $89.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 9.00 $9.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.78 $888.90 $500.00
SENS -V5264 EARMOLD 1 1 0.89 $16.64 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 167 177 814.40 $55281.30 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 23.57 $311.14 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.29 $28.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 282 401 1996.52 $998.26 $0.50
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Subtotal (Total Children Is Unduplicated) 338 2338 7720.18 $429274.58 $55.60
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Total 2704 8384.18 $471554.78 $56.24
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Number of Children (Unduplicated) With at Least One Authorization 366