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: 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 -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.22 $13.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 75 77 189.00 $9450.00 $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 28 28 56.00 $3108.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 105 106 210.00 $15750.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 17 17 33.00 $2475.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 55 55 110.00 $8250.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 108 108 214.00 $11877.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 28.00 $2100.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 26 30.00 $1455.00 $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 6 6 6.00 $291.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 27 42.57 $2064.71 $48.50
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Subtotal (Total Children Is Unduplicated) 265 479 944.79 $58513.44 $61.93
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 19.00 $28500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 3.33 $166.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 187 301 606.57 $30328.57 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 155 162 326.00 $16300.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 75 150.00 $7500.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 74 75 149.00 $7450.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 134 140 282.00 $14100.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 6 39.43 $985.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 15 68.43 $1710.72 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 22 24 137.84 $6891.91 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 5.83 $145.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 142 146 814.48 $40724.08 $50.00
INTR -INTR INTERPRETER 5 6 19.86 $992.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 38 39 197.73 $13421.84 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.10 $168.39 $54.32
PHY -97110 PT SESSION BY LICENSED PT 51 52 233.95 $15880.27 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 21.00 $21.00 $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 0.44 $8.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 105 116 651.72 $44238.70 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 55.71 $735.43 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 225 335 12879.21 $6439.61 $0.50
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Subtotal (Total Children Is Unduplicated) 345 1545 16674.63 $238109.78 $14.28
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Total 2024 17619.43 $296623.22 $16.84
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Number of Children (Unduplicated) With at Least One Authorization 416