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: 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
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 -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 94 94 179.79 $13483.93 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $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 90 97 109.00 $5286.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 39 42 42.00 $2037.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 90 99 99.00 $4801.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 52 54 60.71 $2944.64 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 3 3 3.00 $150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 241 268 268.00 $12998.00 $48.50
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Subtotal (Total Children Is Unduplicated) 429 666 777.50 $42784.57 $55.03
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 257 286 342.03 $17101.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 233 241 346.77 $17338.54 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 129 183.13 $9156.59 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 112 121 159.91 $7995.49 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 220 233 313.07 $15653.42 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 249 260 1724.80 $86239.86 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.43 $121.67 $50.00
INTR -INTR INTERPRETER 8 9 130.00 $6500.01 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 119 133 883.58 $59977.52 $67.88
PHY -97110 PT SESSION BY LICENSED PT 129 146 994.90 $67533.83 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 97 97 97.00 $97.00 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 234 261 1781.01 $120894.67 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.61 $580.48 $50.00
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Subtotal (Total Children Is Unduplicated) 594 1926 6977.24 $410834.44 $58.88
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Total 2592 7754.74 $453619.01 $58.50
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Number of Children (Unduplicated) With at Least One Authorization 624