Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 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 278 307 384.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 278 307 384.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 9 11.29 $1350.67 $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 71 71 162.00 $12150.00 $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 113 113 237.50 $13181.25 $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 203 325 350.71 $17009.64 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 179 185 192.43 $9332.79 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 215 369 402.71 $19531.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 156 164 164.00 $7954.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 682 1058 1071.21 $51953.89 $48.50
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Subtotal (Total Children Is Unduplicated) 943 2408 2776.51 $145740.84 $52.49
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 3.09 $154.52 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 302 370 471.62 $23581.19 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 30 32 38.00 $950.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 394 594 2401.26 $120062.92 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 145 203 851.39 $42569.64 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 133 190 806.52 $40326.22 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.30 $57.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 405 573 2246.19 $112309.70 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.90 $506.60 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 611 967 14331.75 $716587.45 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 8.36 $417.86 $50.00
INTR -INTR INTERPRETER 27 48 332.77 $16638.31 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 287 514 7143.14 $484876.32 $67.88
PHY -97110 PT SESSION BY LICENSED PT 309 559 8152.25 $553374.66 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 62 67 70.18 $70.18 $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 6 7 71.14 $16869.40 $237.12
SENS -V5264 EARMOLD 9 12 19.00 $355.68 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 686 1107 15203.56 $1032017.60 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 10 141.78 $7088.89 $50.00
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Subtotal (Total Children Is Unduplicated) 1188 5264 52310.20 $3179692.61 $60.79
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Total 7979 55470.71 $3325433.46 $59.95
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Number of Children (Unduplicated) With at Least One Authorization 1221