Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 19 20.00 $970.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.00 $10.62 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 17 17 16.23 $974.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 5 8.00 $400.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 44 47 75.54 $3776.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.50 $112.50 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 27 39.00 $2925.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 3.50 $262.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 13.50 $1012.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 21 32.50 $1803.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 284 286 387.79 $29083.94 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 32 38.50 $2887.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 72 73 119.64 $8973.22 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 255 255 358.50 $19896.76 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 239 252 350.36 $26276.79 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 27.14 $1316.43 $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 16 16 25.14 $1219.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 26.14 $1267.93 $48.50
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Subtotal (Total Children Is Unduplicated) 606 1114 1562.48 $104423.36 $66.83
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 37 49 54.00 $81000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 23.64 $1182.15 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 53 59 74.56 $3727.98 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 21 24 20.60 $515.06 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 21.50 $1075.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 16 18 34.51 $862.74 $25.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 14.80 $370.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 10.23 $511.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 11 11 27.72 $693.10 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 11.20 $559.77 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 40 42 53.96 $1349.11 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 35 36 238.50 $5962.50 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 54.14 $2707.14 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 257 267 1513.99 $75699.30 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 0.14 $7.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 5.43 $271.43 $50.00
INTR -INTR INTERPRETER 14 14 66.63 $3331.31 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 105 117 740.94 $50294.89 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 76.21 $4139.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 188 1112.04 $75485.50 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 13 81.82 $4444.67 $54.32
RSPT -RSPT RESPITE 1 1 49.07 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 18 218.16 $218.16 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 5 5 6.93 $129.79 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 2 7.57 $378.57 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 484 533 3356.99 $227872.48 $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 25 25 216.64 $2859.69 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 13.00 $1300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 691 941 4728.13 $2364.06 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 31.57 $1578.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 17.86 $892.86 $50.00
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Subtotal (Total Children Is Unduplicated) 914 2439 12891.50 $558838.89 $43.35
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Total 3553 14453.98 $663262.25 $45.89
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Number of Children (Unduplicated) With at Least One Authorization 1247