Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 19 20 20.00 $970.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 3.00 $108.21 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.00 $10.62 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 11.00 $660.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 10.00 $1196.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 6 10.00 $500.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 45 48 76.54 $3826.79 $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 20 20 28.50 $1581.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 285 287 389.79 $29233.94 $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 257 257 361.50 $20063.26 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 239 253 351.36 $26351.79 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 18.00 $873.00 $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 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 11 11 13.71 $665.14 $48.50
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Subtotal (Total Children Is Unduplicated) 584 1099 1526.54 $102985.84 $67.46
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 34 40 45.00 $67500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 41.58 $2078.82 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 53 58 71.39 $3569.65 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 15 6.96 $174.11 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 18.40 $919.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 11 42.48 $1062.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.43 $21.43 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 21.17 $529.29 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 9.97 $498.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 10 23.37 $584.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 39.28 $1963.91 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 28 30 50.71 $1267.77 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 29 231.14 $5778.57 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 29.43 $1471.44 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 276 285 1633.89 $81694.57 $50.00
INTR -INTR INTERPRETER 23 24 134.04 $6701.79 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 104 109 826.71 $56117.41 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 32.57 $1769.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 149 165 1146.21 $77804.68 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 38.43 $2087.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 44 44 47.92 $47.92 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 8.00 $4000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 8 8 15.53 $290.78 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 15.34 $767.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 472 517 3391.60 $230222.05 $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 47 47 390.79 $5158.36 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 11.29 $1128.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 695 1016 5220.03 $2610.01 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 29.57 $1478.58 $50.00
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Subtotal (Total Children Is Unduplicated) 888 2497 13580.23 $566426.45 $41.71
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Total 3596 15106.77 $669412.29 $44.31
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Number of Children (Unduplicated) With at Least One Authorization 1033