Summary Report for FSPSAs Initiated During the Report Period Center: 05
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
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 14 20.03 $1202.01 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.00 $450.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 69 84 128.00 $6400.00 $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 10 10 13.00 $975.00 $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 4 4 7.00 $525.00 $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 82 82 100.00 $5550.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 381 384 514.00 $38550.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 108 108 139.00 $10425.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 165 166 220.93 $16569.65 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 213 215 321.07 $17819.47 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 243 246 294.50 $22087.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 116 131 131.00 $6353.50 $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 44 44 44.00 $2134.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 0.73 $36.67 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 81 98 98.00 $4753.00 $48.50
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Subtotal (Total Children Is Unduplicated) 700 1621 2074.27 $135950.36 $65.54
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 80 105 137.00 $205500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 14 61.87 $3093.33 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 729 2640 5577.14 $278857.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 696 1089 2231.18 $111559.05 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 356 551 1320.86 $66042.86 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 354 540 1080.00 $54000.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 599 899 2042.86 $102142.86 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 10.00 $250.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 18 21 76.77 $1919.16 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 91 128 519.60 $12990.05 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 71 90 1566.29 $78314.31 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 579 921 13113.88 $655694.01 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 11.00 $550.00 $50.00
INTR -INTR INTERPRETER 12 18 56.86 $2842.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 227 348 3915.56 $265788.12 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.93 $322.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 275 437 4457.53 $302577.41 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 13.29 $721.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 11.00 $11.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 4 4.22 $2111.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 0.55 $35.44 $65.00
SENS -V5264 EARMOLD 5 6 16.58 $310.34 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 518 760 8341.37 $566211.93 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 136.43 $1800.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 4 15.71 $1571.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 827 1868 4947.32 $2473.66 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 2 17.07 $853.57 $50.00
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Subtotal (Total Children Is Unduplicated) 883 10476 49689.84 $2718594.19 $54.71
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Total 12097 51764.11 $2854544.55 $55.15
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Number of Children (Unduplicated) With at Least One Authorization 898