Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 14.79 $547.07 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 14.79 $547.07 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.00 $242.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 18 17.82 $1069.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 7.00 $837.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 11 16.00 $800.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 62 65 90.96 $4548.22 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 35.00 $2625.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 10 15.50 $1162.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 32.50 $1803.75 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 348 351 497.00 $37275.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 31 31 42.00 $3150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 99 99 152.50 $11437.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 300 302 423.00 $23476.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 325 334 452.50 $33937.50 $75.00
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 13 13 13.00 $630.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 9.00 $436.50 $48.50
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Subtotal (Total Children Is Unduplicated) 691 1322 1833.79 $124917.28 $68.12
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 17 18.00 $27000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 16 37.17 $1858.58 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 70 79 100.43 $5021.44 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 15 15 5.82 $145.54 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 12 23.64 $1182.02 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 21 52.38 $1309.41 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 13.72 $686.19 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 14.97 $374.29 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 6.75 $337.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 10 29.07 $726.84 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 25 32.68 $1634.18 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 29 31 37.04 $926.02 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 30 32 179.14 $4478.58 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 40.71 $2035.71 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 292 305 1571.61 $78580.51 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.00 $100.00 $50.00
INTR -INTR INTERPRETER 22 24 129.22 $6461.18 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 75 80 583.98 $39640.63 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 61.43 $3336.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 131 140 949.66 $64462.95 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 67.43 $3662.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 41 43 132.36 $132.36 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 8 9 14.45 $270.54 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 7.00 $350.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 466 534 3154.09 $214099.74 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 9.43 $512.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 43 52 321.11 $4238.62 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 778 1118 4838.97 $2419.48 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 15.14 $757.14 $50.00
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Subtotal (Total Children Is Unduplicated) 977 2610 12456.42 $469395.47 $37.68
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Total 3936 14304.99 $594859.81 $41.58
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Number of Children (Unduplicated) With at Least One Authorization 1335