Summary Report for FSPSAs Initiated During the Report Period Center: 51
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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 2.31 $138.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.67 $797.72 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 13.07 $653.57 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 16.00 $1200.00 $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 2 2 3.00 $225.00 $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 15 15 19.00 $1425.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 12 15.00 $727.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.00 $582.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 24 25 32.14 $1558.93 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 73 112 146.20 $9107.98 $62.30
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 7 32.87 $1643.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.50 $75.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 85 90 147.43 $7371.51 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 46 59.56 $2977.78 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.93 $48.20 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 49 61.42 $3071.12 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 76 106.22 $5310.92 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 2.14 $157.33 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 99.14 $4957.14 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 104 107 868.85 $43442.75 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 5.21 $260.48 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 68 68 399.25 $27101.24 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 26.93 $1462.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 71 74 511.99 $34753.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 54.43 $2956.56 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 2.26 $42.22 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 10.20 $510.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 121 131 923.46 $62684.30 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.43 $186.24 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 25.86 $341.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 454.29 $227.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 24.00 $1200.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 240 686 3827.85 $203292.66 $53.11
-----------------------------------------------------------------------------------------------------------------------------
Total 798 3974.05 $212400.64 $53.45
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 252