Summary Report for FSPSAs Ending During the Report Period Center: 09
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 234 234 274.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 234 234 274.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.34 $12.42 $36.07
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.79 $224.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 6.00 $333.00 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.00 $388.00 $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 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 29 33 33.13 $2135.74 $64.46
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 8.00 $12000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.47 $32.14 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.86 $58.92 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 13 14 32.72 $1635.96 $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 33 36 44.69 $2234.29 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 34 36.23 $1811.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 23 23.00 $1150.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 56 63.76 $3188.10 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 28.57 $2097.71 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 21.14 $528.57 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.00 $50.00 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 2 2 6.50 $324.77 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 3 3 5.71 $285.72 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 322 353 1757.08 $87853.88 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 11.00 $550.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 388 444 1932.85 $131202.15 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 7 10.82 $587.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 325 371 1526.69 $103631.53 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 8.57 $465.60 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 8.00 $4000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 1.12 $73.01 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 13 13 15.79 $295.57 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 744 869 4062.80 $275782.63 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.71 $115.03 $13.20
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Subtotal (Total Children Is Unduplicated) 1097 2275 9624.08 $630582.15 $65.52
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Total 2542 9931.21 $632717.90 $63.71
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Number of Children (Unduplicated) With at Least One Authorization 1130