Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 01/01/08 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 280 310 388.60 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 280 310 388.60 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.31 $3.36 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.31 $6.78 $21.79
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 9.29 $1111.47 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 17 17 17.00 $850.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.07 $230.36 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 3.00 $225.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.57 $42.86 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 7.50 $416.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 66 66 120.00 $9000.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 42 42 75.50 $5662.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 24 24 45.00 $3375.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 108 108 195.50 $10850.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 18 33.00 $2475.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 194 335 343.54 $16661.64 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 168 174 181.43 $8799.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 227 403 430.29 $20868.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 163 172 172.00 $8342.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 661 1070 1082.21 $52487.39 $48.50
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Subtotal (Total Children Is Unduplicated) 977 2452 2719.53 $141407.99 $52.00
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 6.00 $9000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 300 366 464.62 $23231.19 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 30 32 38.00 $950.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 343 535 2280.12 $114006.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 114 163 703.52 $35176.24 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 105 152 661.93 $33096.27 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 344 500 2026.93 $101346.36 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.90 $506.60 $73.42
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 139 140 840.76 $42038.10 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 518 856 13021.44 $651072.20 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 10.40 $520.00 $50.00
INTR -INTR INTERPRETER 29 50 349.05 $17452.71 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 300 523 6986.28 $474228.42 $67.88
PHY -97110 PT SESSION BY LICENSED PT 330 606 8197.74 $556462.91 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 23.70 $23.70 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 6 69.14 $16395.16 $237.12
SENS -V5264 EARMOLD 8 10 15.00 $280.80 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 660 1109 14425.73 $979218.73 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 14 208.78 $10438.81 $50.00
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Subtotal (Total Children Is Unduplicated) 1151 5095 50339.06 $3067322.35 $60.93
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Total 7857 53447.18 $3208730.34 $60.04
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Number of Children (Unduplicated) With at Least One Authorization 1255