Summary Report for FSPSAs Initiated During the Report Period Center: 06
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting between: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 2.35 $87.05 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 2.35 $87.05 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 20.81 $1248.58 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 10.13 $474.24 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 10.47 $1251.82 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.00 $194.00 $48.50
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Subtotal (Total Children Is Unduplicated) 32 43 56.41 $3780.13 $67.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 21 22 27.54 $1376.97 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 55 80.86 $4042.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 34 52.19 $2609.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 6.43 $160.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 77 93.94 $4696.95 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 9 11.03 $275.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 44 54.11 $2705.30 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 6.66 $166.46 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 76 118.98 $5948.82 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 6 10.61 $265.18 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 79 1000.14 $25003.59 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 195 221 1447.80 $72390.01 $50.00
INTR -INTR INTERPRETER 13 13 43.36 $2167.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 136 159 649.94 $44118.08 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 9 65.48 $3556.66 $54.32
PHY -97110 PT SESSION BY LICENSED PT 179 207 904.21 $61378.01 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 3.36 $182.36 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 7 9.86 $9.86 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 8 8 8.00 $4000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 10 10 7.27 $136.03 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 430 493 2589.03 $175743.27 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.71 $473.36 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 13 14 96.29 $1270.97 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 5 8.13 $813.34 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 52.07 $2603.58 $50.00
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Subtotal (Total Children Is Unduplicated) 748 1580 7369.98 $434357.62 $58.94
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Total 1627 7428.75 $438224.81 $58.99
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Number of Children (Unduplicated) With at Least One Authorization 754