Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 4.70 $282.00 $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 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 8 11 11.00 $550.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 60 68.71 $3332.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 26 26.00 $1261.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 14 14 14.00 $700.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 72 80 83.43 $4046.29 $48.50
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Subtotal (Total Children Is Unduplicated) 151 202 213.84 $10505.62 $49.13
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 4 6.60 $330.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.35 $17.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 54 55 67.11 $3355.72 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 22 17.40 $870.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 23 22.20 $1110.01 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 64 68.42 $3420.84 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.43 $485.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 140 161 770.70 $38535.23 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 67 74 371.42 $25211.75 $67.88
PHY -97110 PT SESSION BY LICENSED PT 77 80 313.60 $21287.22 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.88 $47.98 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 2.82 $2.82 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.70 $13.10 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 5.00 $250.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 215 237 983.24 $66742.20 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 42.14 $556.29 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 277 441 159173.79 $79586.89 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 18.71 $935.72 $50.00
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Subtotal (Total Children Is Unduplicated) 354 1188 161891.52 $249358.97 $1.54
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Total 1391 162106.36 $259864.60 $1.60
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Number of Children (Unduplicated) With at Least One Authorization 408