Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $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 2 2 0.91 $54.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 5.00 $598.00 $119.60
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 2 2 2.00 $111.00 $55.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 3 3.00 $145.50 $48.50
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Subtotal (Total Children Is Unduplicated) 13 18 16.91 $1224.97 $72.44
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 11 21.52 $1076.03 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 14.23 $711.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 26 30.54 $1527.15 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 18.86 $942.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 43 60.61 $3030.71 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 16 26.86 $1971.86 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.71 $67.86 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 14.29 $714.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 245 331 1593.20 $79660.00 $50.00
INTR -INTR INTERPRETER 3 4 6.43 $321.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 326 439 1857.93 $126116.38 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 8 16.44 $893.17 $54.32
PHY -97110 PT SESSION BY LICENSED PT 280 357 1541.92 $104665.80 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 14.79 $803.16 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 4 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 6 0.57 $24.39 $43.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 10 11 10.29 $192.61 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.93 $96.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 604 846 3855.92 $261739.51 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 6.86 $90.51 $13.20
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Subtotal (Total Children Is Unduplicated) 881 2152 9111.89 $597647.04 $65.59
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Total 2172 9130.81 $598872.01 $65.59
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Number of Children (Unduplicated) With at Least One Authorization 883