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: 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 -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.09 $65.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 47 49 122.00 $6100.00 $50.00
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 21 21 42.00 $2331.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 80 80 160.00 $12000.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 17 17 34.00 $2550.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 43 43 86.00 $6450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 92 92 184.00 $10212.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 14.00 $1050.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 25 44.86 $2175.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 17.10 $829.35 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 195 358 714.05 $44198.05 $61.90
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 17 21.00 $31500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 10.50 $525.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 164 303 634.36 $31717.86 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 132 145 314.86 $15742.86 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 67 136.00 $6800.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.00 $100.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 70 76 151.50 $7575.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 124 248.00 $12400.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.00 $150.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 6 47.29 $1182.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 92.78 $2319.40 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 16 100.07 $5003.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 115 119 788.70 $39435.03 $50.00
INTR -INTR INTERPRETER 2 2 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 32 34 187.71 $12741.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 28.00 $1520.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 59 59 267.59 $18164.21 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 24 32.00 $32.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 0.16 $2.91 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 86 95 587.36 $39870.11 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 60.43 $797.66 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 208 303 3901.42 $1950.71 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 298 1417 7625.72 $230781.14 $30.26
-----------------------------------------------------------------------------------------------------------------------------
Total 1775 8339.76 $274979.20 $32.97
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 355