Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.79 $103.07 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
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 4 4 5.00 $625.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 12 14 14.00 $700.00 $50.00
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 52 56 56.00 $2716.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 25 25.00 $1212.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 13 13 13.00 $650.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 68 75 75.00 $3637.50 $48.50
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Subtotal (Total Children Is Unduplicated) 144 192 194.00 $9971.36 $51.40
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 7.00 $350.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.87 $143.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 42 47 56.02 $2800.84 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 32 38.68 $1934.17 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 28 35.31 $1765.72 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 58 67.25 $3362.51 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.51 $62.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.86 $21.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 170 796.28 $39813.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 7.29 $364.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 71 79 464.79 $31549.67 $67.88
PHY -97110 PT SESSION BY LICENSED PT 101 115 479.82 $32569.89 $67.88
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 2 5.69 $106.50 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 216 242 1077.09 $73112.84 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 53.62 $707.74 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 291 433 167609.74 $83804.87 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 5.39 $269.29 $50.00
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Subtotal (Total Children Is Unduplicated) 384 1235 170719.49 $282772.26 $1.66
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Total 1428 170916.27 $292846.69 $1.71
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Number of Children (Unduplicated) With at Least One Authorization 414