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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 4 4 5.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 4 4 5.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 31 31 59.50 $4462.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 34 35 64.50 $4837.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 16 16 30.00 $2250.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 73 73 136.00 $7548.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.00 $450.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 54 57 66.00 $3201.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 45 45 45.00 $2182.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 79 84 84.00 $4074.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 37 38 38.00 $1843.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 213 230 230.00 $11155.00 $48.50
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Subtotal (Total Children Is Unduplicated) 375 618 767.00 $42723.40 $55.70
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 134 149 189.35 $9467.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 13 13 14.00 $350.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 113 121 216.18 $10809.23 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 46 85.79 $4289.38 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 39 76.17 $3808.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 137 236.58 $11828.99 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 199 219 1320.98 $66049.06 $50.00
INTR -INTR INTERPRETER 8 8 57.93 $2896.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 98 104 671.73 $45597.07 $67.88
PHY -97110 PT SESSION BY LICENSED PT 119 128 797.90 $54161.47 $67.88
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 5.00 $93.60 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 225 245 1502.35 $101979.26 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 16.19 $809.45 $50.00
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Subtotal (Total Children Is Unduplicated) 461 1220 5195.15 $317264.12 $61.07
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Total 1842 5967.15 $359987.52 $60.33
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Number of Children (Unduplicated) With at Least One Authorization 537