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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 4 4 8.00 $400.00 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 93 93 177.79 $13333.93 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.00 $333.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 7.00 $525.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 83 98 98.00 $4753.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 71 72 72.00 $3492.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 89 106 114.57 $5556.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 52 55 55.00 $2667.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 287 344 344.00 $16684.00 $48.50
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Subtotal (Total Children Is Unduplicated) 494 789 895.36 $48739.94 $54.44
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 259 288 346.03 $17301.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 203 220 301.82 $15091.09 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 120 137 202.00 $10099.78 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 95 107 156.37 $7818.26 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 211 235 317.18 $15859.14 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 242 1320.78 $66039.13 $50.00
INTR -INTR INTERPRETER 11 13 126.64 $6332.07 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 139 169 1129.15 $76646.52 $67.88
PHY -97110 PT SESSION BY LICENSED PT 133 165 970.98 $65910.20 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 87 93 93.00 $93.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 5 5 9.00 $168.48 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 5.50 $275.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 283 339 2085.71 $141578.25 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 4.00 $200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 615 2025 7078.16 $424723.16 $60.00
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Total 2814 7973.52 $473463.11 $59.38
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Number of Children (Unduplicated) With at Least One Authorization 707