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: 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 -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.08 $64.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 52 52 95.00 $4750.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.00 $300.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.00 $150.00 $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 110 111 222.00 $16650.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 25 50.00 $3750.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 58 59 118.00 $8850.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 123 123 246.00 $13653.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 28.00 $2100.00 $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 22 22 25.57 $1240.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 18 20.00 $970.00 $48.50
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Subtotal (Total Children Is Unduplicated) 234 458 861.65 $55273.18 $64.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 28 34.00 $51000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 4.74 $237.14 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 283 561 1124.07 $56203.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 265 276 554.13 $27706.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 116 120 238.00 $11900.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 144 153 305.00 $15250.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 224 237 476.20 $23810.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 12.00 $300.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 33 256.08 $6402.02 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 22.57 $1128.58 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 230 237 1359.73 $67986.43 $50.00
INTR -INTR INTERPRETER 5 6 12.00 $600.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 67 70 296.90 $20153.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.07 $58.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 91 98 377.02 $25592.35 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 8.93 $485.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 6.40 $6.40 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 2 2 2.51 $47.01 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 175 186 850.29 $57717.73 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 48.57 $641.15 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 330 458 2204.88 $1102.44 $0.50
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Subtotal (Total Children Is Unduplicated) 379 2497 8196.11 $368828.34 $45.00
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Total 2955 9057.76 $424101.52 $46.82
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Number of Children (Unduplicated) With at Least One Authorization 416