Summary Report for FSPSAs Ending During the Report Period Center: 05
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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.00 $74.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.48 $28.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 61 67 158.43 $7921.43 $50.00
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 27 27 54.00 $2997.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 113 113 226.00 $16950.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 19 19 38.00 $2850.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 46 46 92.00 $6900.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 109 109 218.00 $12099.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 18 36.00 $2700.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 26 46.71 $2265.64 $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 12 12 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 25 35.71 $1732.14 $48.50
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Subtotal (Total Children Is Unduplicated) 254 465 920.33 $57169.68 $62.12
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 27 40.00 $60000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.07 $153.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 196 360 717.90 $35895.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 167 180 362.33 $18116.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 75 158.19 $7909.52 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.00 $100.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 89 181.17 $9058.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 153 159 328.59 $16429.52 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 4 8.00 $200.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 64.39 $1609.77 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 13 71.73 $3586.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 147 150 846.11 $42305.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 44 169.11 $11479.34 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 12.43 $675.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 72 73 234.49 $15917.05 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 18.00 $977.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 26.30 $26.30 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.19 $77.47 $65.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 131 132 590.49 $40082.78 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.86 $263.84 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 58.14 $767.48 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 10.14 $1014.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 274 339 1912.45 $956.23 $0.50
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Subtotal (Total Children Is Unduplicated) 367 1697 5824.09 $268101.73 $46.03
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Total 2163 6746.43 $325345.41 $48.22
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Number of Children (Unduplicated) With at Least One Authorization 435