Summary Report for FSPSAs Ending During the Report Period Center: 09
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 249 249 254.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 249 249 254.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.00 $145.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.72 $43.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.72 $33.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 5.00 $277.50 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 20.00 $970.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 8 11.14 $540.43 $48.50
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Subtotal (Total Children Is Unduplicated) 44 49 52.59 $2910.96 $55.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 17.28 $864.05 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 15 15.47 $773.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 19.91 $995.72 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 11.14 $557.15 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 25 42.08 $2103.81 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 17 17 66.36 $4871.95 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 14.29 $714.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 13.00 $650.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 18 18 103.14 $5157.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 261 293 1546.79 $77339.32 $50.00
INTR -INTR INTERPRETER 2 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 369 455 2202.77 $149523.85 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 14.34 $778.85 $54.32
PHY -97110 PT SESSION BY LICENSED PT 314 361 1942.20 $131836.87 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.00 $54.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 1.88 $80.92 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 5 5 5.97 $111.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 703 855 4565.02 $309873.86 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 9.14 $120.69 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1004 2108 10610.79 $699000.37 $65.88
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Total 2406 10917.52 $701911.33 $64.29
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Number of Children (Unduplicated) With at Least One Authorization 1023