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: 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
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 3 3 2.26 $135.34 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 20 20 38.00 $1900.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 5 10.00 $555.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 17 17 31.00 $1720.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 86 86 165.00 $12375.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 42.00 $3150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 40 40 77.00 $5775.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 73 73 144.14 $7999.93 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 33 34 59.00 $4425.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 30 30.00 $1455.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.00 $388.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 0.73 $36.67 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 29 29.00 $1406.50 $48.50
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Subtotal (Total Children Is Unduplicated) 191 381 657.13 $42822.00 $65.17
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 21 23.00 $34500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 11.57 $578.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 237 499 998.00 $49900.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 235 243 487.47 $24373.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 110 119 238.00 $11900.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 124 128 256.00 $12800.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 208 220 440.00 $22000.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.00 $50.00 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 3 3.83 $95.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 33 36 90.65 $2266.30 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 11 90.00 $4500.01 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 214 1392.01 $69600.75 $50.00
INTR -INTR INTERPRETER 4 5 9.00 $450.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 61 64 317.93 $21581.01 $67.88
PHY -97110 PT SESSION BY LICENSED PT 98 100 456.83 $31009.37 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 10.00 $10.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.22 $611.10 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.04 $2.67 $65.00
SENS -V5264 EARMOLD 1 1 0.61 $11.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 159 170 837.46 $56846.92 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 7.57 $99.94 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 12.71 $1271.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 292 393 1677.49 $838.74 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 4.00 $200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 340 2249 7367.40 $345497.42 $46.90
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Total 2630 8024.53 $388319.42 $48.39
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Number of Children (Unduplicated) With at Least One Authorization 363