Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 133 135 135.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 133 135 135.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.00 $242.50 $48.50
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.00 $48.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.00 $32.40 $10.80
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 2 2 2.00 $42.68 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 7.08 $424.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 12.00 $561.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 16 18.00 $2152.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.00 $450.00 $50.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 23 23.00 $1276.50 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.00 $242.50 $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 2 2 2.00 $97.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 10 16.93 $821.04 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 73 101 113.01 $6662.56 $58.96
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 18 19.00 $28500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 2.34 $161.44 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.98 $205.04 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 28 34 200.59 $10029.70 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 72 91 134.26 $6713.09 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 110 158.15 $7907.38 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.00 $50.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 62 92.64 $4632.15 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 183 294.99 $14749.53 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 27 32 144.21 $10588.21 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 6 28.29 $707.15 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 5 16.29 $814.29 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 4 4 14.57 $728.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 677 1137 13038.49 $651924.62 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 28.21 $1410.72 $50.00
INTR -INTR INTERPRETER 6 9 39.71 $1985.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 791 1612 16084.69 $1091828.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 19 99.50 $5405.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 664 1279 14440.66 $980232.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 60.57 $3290.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 15 15.00 $15.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 13 15 17.00 $8500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 18 19 13.86 $900.80 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 29 34 80.92 $1514.91 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 15.18 $758.81 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1485 2985 31583.75 $2143904.80 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 63.71 $841.03 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 17.14 $857.15 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2054 7703 76719.73 $4980966.19 $64.92
-----------------------------------------------------------------------------------------------------------------------------
Total 7939 76967.74 $4987628.75 $64.80
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 2059