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: 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
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.67 $438.54 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 62 64 151.00 $7550.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.00 $450.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 6 12.00 $666.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 16 16 32.00 $1776.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 79 80 158.00 $11850.00 $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 50 50 100.00 $7500.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 97 97 193.00 $10711.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 6 12.00 $900.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 26 31.00 $1503.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 23 28.00 $1358.00 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 232 402 777.67 $48163.82 $61.93
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 19 24.00 $36000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 20.86 $1042.86 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 159 278 555.57 $27778.57 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 133 139 279.80 $13990.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 66 131.80 $6590.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.00 $75.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 83 165.80 $8290.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.00 $50.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 130 258.30 $12915.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.00 $150.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 22.80 $570.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 18 162.67 $4066.67 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 18 125.21 $6260.73 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 7.57 $189.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 136 140 899.88 $44994.01 $50.00
INTR -INTR INTERPRETER 9 9 13.00 $650.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 29 29 135.30 $9183.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.71 $147.44 $54.32
PHY -97110 PT SESSION BY LICENSED PT 59 61 218.01 $14798.65 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 10.71 $581.74 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 19.00 $19.00 $1.00
SENS -V5264 EARMOLD 2 2 1.81 $33.90 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 109 117 582.55 $39543.32 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 55.56 $733.42 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 9.14 $914.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 211 264 3574.62 $1787.31 $0.50
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Subtotal (Total Children Is Unduplicated) 329 1415 7287.68 $231355.01 $31.75
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Total 1817 8065.35 $279518.83 $34.66
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Number of Children (Unduplicated) With at Least One Authorization 394