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: 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.20 $262.80 $119.60
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.07 $155.36 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $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 2 2 2.50 $138.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 35 35 60.50 $4537.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 11.50 $862.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 59.50 $3302.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 12 21.50 $1612.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 68 74 74.00 $3589.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 57 57.00 $2764.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 86 100 111.14 $5390.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 48 48.00 $2328.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 244 275 278.00 $13483.00 $48.50
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Subtotal (Total Children Is Unduplicated) 396 656 738.48 $39219.43 $53.11
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 167 189 240.34 $12016.91 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 16 20.00 $500.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 140 149 239.43 $11971.70 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 50 80.42 $4021.24 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 53 71.37 $3568.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 150 233.54 $11677.23 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.83 $61.18 $73.42
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 216 1404.32 $70215.82 $50.00
INTR -INTR INTERPRETER 5 5 61.86 $3092.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 121 132 928.41 $63020.67 $67.88
PHY -97110 PT SESSION BY LICENSED PT 133 156 1119.93 $76020.79 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 21 19.09 $19.09 $1.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 43.14 $10230.04 $237.12
SENS -V5264 EARMOLD 2 2 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 246 282 1822.43 $123706.50 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 5.43 $271.43 $50.00
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Subtotal (Total Children Is Unduplicated) 500 1428 6298.55 $393696.67 $62.51
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Total 2085 7038.03 $432916.10 $61.51
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Number of Children (Unduplicated) With at Least One Authorization 552