Summary Report for FSPSAs Ending During the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 12 19.28 $1156.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 21 21 21.00 $1050.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 52 66 95.00 $4750.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 12.00 $900.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 8.00 $600.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 14 19.00 $1054.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 73 73 82.00 $4551.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 365 367 468.00 $35100.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 101 101 124.00 $9300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 152 153 189.93 $14244.65 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 199 200 277.07 $15377.47 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 242 245 290.50 $21787.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 110 123 123.00 $5965.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 54 56 56.00 $2716.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 87 99 99.00 $4801.50 $48.50
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Subtotal (Total Children Is Unduplicated) 698 1553 1895.78 $124204.36 $65.52
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 79 94 121.00 $181500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 10 48.65 $2432.38 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 693 2167 4570.43 $228521.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 658 1087 2258.57 $112928.57 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 332 538 1248.14 $62407.15 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 338 544 1119.86 $55992.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 561 881 1937.71 $96885.72 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 10.00 $250.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 16 17 68.73 $1718.33 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 20 20 39.17 $979.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 91 331.13 $8278.15 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 74 98 1497.43 $74871.44 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 151 151 982.44 $49122.17 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 499 740 11693.70 $584684.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 11.00 $550.00 $50.00
INTR -INTR INTERPRETER 17 23 52.07 $2603.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 235 367 4039.98 $274233.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 7.00 $380.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 278 459 4546.44 $308612.44 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.29 $721.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 3 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.50 $32.77 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.50 $355.68 $237.12
SENS -V5264 EARMOLD 5 6 15.01 $281.01 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 502 777 8627.69 $585647.27 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.15 $8.15 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 158.93 $2097.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 4 7.13 $713.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 875 1820 3930.94 $1965.47 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 29.14 $1457.15 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 3 58.21 $2910.72 $50.00
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Subtotal (Total Children Is Unduplicated) 966 9928 47431.95 $2644694.49 $55.76
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Total 11481 49327.73 $2768898.85 $56.13
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Number of Children (Unduplicated) With at Least One Authorization 996