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: 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 3 3 4.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 4.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.10 $370.27 $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 34 34 71.21 $5341.07 $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 18 18 34.00 $2550.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 78 78 151.71 $8420.14 $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 57 62 74.57 $3616.71 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 43 43 43.00 $2085.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 76 81 82.00 $3977.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 39 39 39.00 $1891.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 246 275 275.00 $13337.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 366 674 848.10 $47118.70 $55.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.07 $3.29 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 137 153 194.29 $9714.29 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 13 13 14.00 $350.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 158 175 310.87 $15543.51 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 46 66.50 $3325.10 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 48 93.72 $4686.16 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 128 140 246.01 $12300.27 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 268 1886.80 $94339.98 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.79 $89.29 $50.00
INTR -INTR INTERPRETER 4 5 12.86 $642.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 96 105 683.93 $46425.07 $67.88
PHY -97110 PT SESSION BY LICENSED PT 110 122 875.42 $59423.77 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 2.71 $2.71 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 22.00 $5216.64 $237.12
SENS -V5264 EARMOLD 4 4 7.00 $131.04 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 254 290 1800.63 $122226.58 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 9.00 $450.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 489 1382 6230.59 $379520.52 $60.91
-----------------------------------------------------------------------------------------------------------------------------
Total 2059 7082.68 $426639.22 $60.24
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 514