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: 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 3 3 3.00 $358.80 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 11 11 22.00 $1100.00 $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 63 63 108.50 $8137.50 $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 65 65 111.50 $6188.25 $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 71 78 78.00 $3783.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 76 76 76.00 $3686.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 88 100 100.00 $4850.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 55 56 61.71 $2993.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 261 284 284.00 $13774.00 $48.50
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Subtotal (Total Children Is Unduplicated) 414 776 912.21 $49825.94 $54.62
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 8.00 $12000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 239 271 337.35 $16867.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 187 196 305.69 $15284.65 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 109 146.75 $7337.46 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 91 99 137.95 $6897.75 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 197 213 294.27 $14713.37 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 230 1381.56 $69077.82 $50.00
INTR -INTR INTERPRETER 12 15 143.33 $7166.39 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 137 153 904.86 $61421.98 $67.88
PHY -97110 PT SESSION BY LICENSED PT 138 159 1029.37 $69873.87 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 82 85 85.00 $85.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
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
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 9.93 $496.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 266 295 1975.64 $134106.29 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 9.14 $457.15 $50.00
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Subtotal (Total Children Is Unduplicated) 571 1843 6784.84 $418621.57 $61.70
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Total 2619 7697.06 $468447.51 $60.86
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Number of Children (Unduplicated) With at Least One Authorization 583