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: 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
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 72 136.36 $10226.78 $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 2 2 3.50 $194.25 $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 84 103 103.00 $4995.50 $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 92 112 112.00 $5432.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 43 45 45.00 $2182.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 241 283 283.00 $13725.50 $48.50
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Subtotal (Total Children Is Unduplicated) 421 694 785.86 $43222.23 $55.00
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 11.00 $16500.00 $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 242 263 382.29 $19114.39 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 130 142 219.75 $10987.52 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 115 131 208.40 $10420.10 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 236 257 343.23 $17161.35 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.80 $45.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 285 305 1852.81 $92640.49 $50.00
INTR -INTR INTERPRETER 13 14 190.92 $9545.99 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 116 139 989.86 $67191.84 $67.88
PHY -97110 PT SESSION BY LICENSED PT 136 160 1161.54 $78845.02 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 80 81 81.00 $81.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 6 6 11.00 $205.92 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 238 281 1948.07 $132234.65 $67.88
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Subtotal (Total Children Is Unduplicated) 607 2077 7741.66 $472072.50 $60.98
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Total 2771 8527.52 $515294.73 $60.43
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Number of Children (Unduplicated) With at Least One Authorization 631