Summary Report for FSPSAs Ending During the Report Period Center: 05
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
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 1 1 1.00 $60.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 23 25 46.00 $2300.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 4.00 $222.00 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.00 $600.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 19 19 37.00 $2053.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 89 89 178.00 $13350.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 46.00 $3450.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 56 56 111.00 $8325.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 104 104 208.00 $11544.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.00 $600.00 $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 21 22 22.00 $1067.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 26 27.53 $1335.37 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 194 387 710.53 $45733.94 $64.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 25 33.00 $49500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.53 $226.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 216 453 944.14 $47207.14 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 225 240 480.73 $24036.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 116 232.00 $11600.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 115 122 244.00 $12200.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 198 213 456.57 $22828.57 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 6.17 $154.17 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 32 36 78.92 $1973.02 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 22 24 162.57 $8128.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 183 199 1090.69 $54534.55 $50.00
INTR -INTR INTERPRETER 4 4 6.43 $321.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 65 69 245.64 $16673.91 $67.88
PHY -97110 PT SESSION BY LICENSED PT 92 101 365.23 $24791.72 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 5.00 $5.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.22 $611.10 $500.00
SENS -V5264 EARMOLD 2 2 0.48 $8.94 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 159 173 747.24 $50722.32 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 1 1 12.57 $1257.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 314 412 1200.42 $600.21 $0.50
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Subtotal (Total Children Is Unduplicated) 360 2203 6317.55 $327380.87 $51.82
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Total 2590 7028.08 $373114.81 $53.09
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Number of Children (Unduplicated) With at Least One Authorization 397