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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 3.00 $358.80 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.00 $100.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 3.50 $262.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 5.50 $305.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 64 64 110.50 $8287.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 43.50 $3262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 66 66 113.50 $6299.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 15.00 $1125.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 90 101 101.00 $4898.50 $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 81 92 96.57 $4683.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 45 46 51.71 $2508.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 246 278 279.00 $13531.50 $48.50
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Subtotal (Total Children Is Unduplicated) 418 723 857.79 $47223.16 $55.05
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 237 269 332.35 $16617.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 159 176 254.12 $12706.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.70 $67.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 74 79 117.99 $5899.44 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 76 124.97 $6248.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.80 $20.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 167 185 262.70 $13134.93 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 243 1443.48 $72174.08 $50.00
INTR -INTR INTERPRETER 10 11 78.33 $3916.31 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 120 136 855.99 $58104.32 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.00 $380.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 125 146 959.53 $65132.67 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 61 69 68.02 $68.02 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 6.00 $112.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 6.43 $321.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 257 296 1895.28 $128651.36 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.43 $171.43 $50.00
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Subtotal (Total Children Is Unduplicated) 518 1706 6430.10 $390475.22 $60.73
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Total 2429 7287.89 $437698.38 $60.06
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Number of Children (Unduplicated) With at Least One Authorization 603