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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 4.00 $300.00 $75.00
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 72 72 135.86 $10189.28 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 16 16 31.50 $2362.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 5.00 $277.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 12.50 $937.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 80 96 97.43 $4725.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 46 47 47.00 $2279.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 89 99 99.00 $4801.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 49 49 57.71 $2799.14 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 233 273 273.00 $13240.50 $48.50
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Subtotal (Total Children Is Unduplicated) 440 666 767.00 $42162.71 $54.97
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 8.00 $12000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 248 278 327.00 $16350.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 10 10 10.00 $250.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 216 241 295.11 $14755.40 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 116 133 170.84 $8542.04 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 94 109 140.14 $7007.24 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 206 227 263.70 $13184.84 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 243 266 1501.58 $75078.81 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.33 $16.67 $50.00
INTR -INTR INTERPRETER 12 13 80.18 $4008.92 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 115 138 851.21 $57780.38 $67.88
PHY -97110 PT SESSION BY LICENSED PT 133 149 889.04 $60348.03 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 93 95 95.00 $95.00 $1.00
SENS -V5264 EARMOLD 2 2 3.00 $56.16 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 231 273 1568.06 $106440.18 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.57 $628.57 $50.00
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Subtotal (Total Children Is Unduplicated) 590 1940 6216.77 $376567.23 $60.57
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Total 2606 6983.77 $418729.95 $59.96
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Number of Children (Unduplicated) With at Least One Authorization 684