Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.75 $27.75 $37.00
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Subtotal (Total Children Is Unduplicated) 1 2 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 14.00 $679.00 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 26 26 27.84 $1670.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 7.43 $347.88 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 11.25 $562.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 41 45 63.04 $3151.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.50 $187.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.50 $83.25 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 19 19 25.86 $1939.28 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 12.00 $900.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 25 25 32.00 $2400.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 46 61.36 $3405.32 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 9.50 $527.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 286 286 383.57 $28767.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 26.50 $1987.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 76 78 127.00 $9525.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 278 285 394.57 $21898.72 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 272 301 411.21 $30841.07 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 22.29 $1080.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 17 18.29 $886.86 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 25 28.57 $1385.71 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 48 50 49.86 $2418.07 $48.50
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Subtotal (Total Children Is Unduplicated) 703 1300 1755.13 $116788.76 $66.54
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 33 40.00 $60000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 14 16 26.71 $1335.71 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 65 67 83.50 $4174.88 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 14 15.83 $395.84 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 18 19.00 $950.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 9.53 $238.21 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 5.20 $260.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 16.82 $420.48 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.50 $125.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 17.52 $438.06 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 48.28 $2413.92 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 14 27.50 $687.52 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.86 $485.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 23 195.21 $4880.36 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 20.00 $1000.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 248 1472.75 $73637.63 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 35.43 $1771.43 $50.00
INTR -INTR INTERPRETER 10 10 134.43 $6721.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 68 73 475.49 $32276.29 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 12 85.04 $4619.14 $54.32
PHY -97110 PT SESSION BY LICENSED PT 132 147 1178.81 $80017.30 $67.88
PHY -97110HM PT SESSION BY PT ASST 17 17 111.19 $6039.87 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.66 $0.66 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 8.00 $4000.00 $500.00
SENS -V5264 EARMOLD 7 8 13.00 $243.36 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 16.00 $800.00 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 7.71 $385.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 402 452 3019.43 $204959.10 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 24.14 $1311.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 18 18 184.14 $2430.69 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 3 16.86 $1685.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 616 871 4566.82 $2283.41 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.57 $178.57 $50.00
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Subtotal (Total Children Is Unduplicated) 790 2116 11920.93 $501236.26 $42.05
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Total 3418 13677.07 $618062.03 $45.19
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Number of Children (Unduplicated) With at Least One Authorization 1200