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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 42 42 42.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 42 42 42.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.00 $21.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92682 CONDITIONED PLAY AUDIOMETRY 1 1 1.00 $21.34 $21.34
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 0.71 $42.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 10.00 $555.00 $55.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $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 1 1 1.00 $48.50 $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) 23 31 29.71 $1741.23 $58.61
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 27.10 $1355.24 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 28 42.83 $2141.43 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 32 33.87 $1693.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 25.00 $1250.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 65 66.47 $3323.34 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 20.29 $1489.38 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 11.29 $282.14 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 2.00 $100.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 312 352 1815.10 $90754.81 $50.00
INTR -INTR INTERPRETER 4 5 22.43 $1121.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 371 448 2079.25 $141139.73 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 7 29.86 $1621.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 336 399 1970.76 $133775.09 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 9 9.00 $9.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 1.60 $103.99 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 14 14 11.36 $212.66 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.50 $225.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 697 822 3911.18 $265491.09 $67.88
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Subtotal (Total Children Is Unduplicated) 1046 2246 10095.88 $655088.74 $64.89
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Total 2319 10167.59 $656829.97 $64.60
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Number of Children (Unduplicated) With at Least One Authorization 1051