Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 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 3 3 6.10 $225.70 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 6.10 $225.70 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 32.98 $1978.58 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 8.43 $1008.06 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 4.00 $200.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 13.00 $975.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 7.00 $525.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 7 11.00 $610.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 12 15.00 $1125.00 $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 15 15 31.14 $1510.43 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 26 41.29 $2002.36 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 7 7 7.00 $350.00 $50.00
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Subtotal (Total Children Is Unduplicated) 80 115 189.83 $11396.60 $60.03
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 21.21 $1060.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 65 71 192.93 $9646.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 34 52.98 $2648.99 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 32 50.89 $2544.49 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.00 $75.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 41 59.02 $2951.09 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 7.57 $555.89 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 111.00 $2775.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 124.29 $6214.29 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 115 122 935.69 $46784.27 $50.00
INTR -INTR INTERPRETER 1 1 4.00 $200.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 79 85 610.56 $41445.07 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 40.79 $2215.73 $54.32
PHY -97110 PT SESSION BY LICENSED PT 79 85 656.18 $44541.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 31.21 $1695.56 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 2 2 1.78 $33.28 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 4.79 $239.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 150 163 1192.48 $80945.43 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.29 $148.97 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 53 81 28622.93 $14311.46 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.50 $125.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 29.15 $1457.38 $50.00
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Subtotal (Total Children Is Unduplicated) 269 762 32792.52 $269071.26 $8.21
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Total 880 32988.45 $280693.56 $8.51
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Number of Children (Unduplicated) With at Least One Authorization 306