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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 23 28 37.00 $1850.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.00 $75.00 $75.00
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 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 13 13 14.00 $777.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 97 97 113.00 $8475.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 26.00 $1950.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 41 46.00 $3450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 17 17 21.00 $1165.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 94 94 108.50 $8137.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 27 27 27.00 $1309.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 19 19.00 $921.50 $48.50
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Subtotal (Total Children Is Unduplicated) 192 373 427.50 $29044.20 $67.94
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 21 30.00 $45000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.21 $110.56 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 322 687 1384.71 $69235.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 248 285 590.43 $29521.43 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 127 140 295.29 $14764.29 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 136 143 286.00 $14300.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 206 222 444.29 $22214.29 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 4.57 $114.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 36 49.64 $1241.12 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 16 96.86 $4842.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 250 1421.98 $71098.86 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 7.00 $350.00 $50.00
INTR -INTR INTERPRETER 5 5 10.00 $500.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 86 93 404.71 $27471.72 $67.88
PHY -97110 PT SESSION BY LICENSED PT 111 115 444.34 $30161.66 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.71 $364.72 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.37 $6.86 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 199 954.38 $64783.37 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 20.86 $275.31 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 344 474 990.14 $495.07 $0.50
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Subtotal (Total Children Is Unduplicated) 397 2704 7448.48 $397501.99 $53.37
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Total 3077 7875.98 $426546.19 $54.16
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Number of Children (Unduplicated) With at Least One Authorization 402