Summary Report for FSPSAs Ending During the Report Period Center: 54
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 13.00 $481.00 $37.00
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Subtotal (Total Children Is Unduplicated) 3 4 14.00 $481.00 $34.36
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 54 56 54.27 $3256.09 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 28 28 28.23 $3376.70 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 7.00 $875.00 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 11 11 11.00 $533.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 62 65 71.43 $3464.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 28.00 $1358.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 104 105 110.71 $5369.64 $48.50
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Subtotal (Total Children Is Unduplicated) 224 313 323.64 $19028.49 $58.79
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 14 27.00 $1350.09 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 6.72 $335.84 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.17 $54.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 62 68 99.79 $4989.30 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 14 12.82 $320.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 38 41.07 $2053.35 $50.00
CONOP -CONOP CONSULT, OT, PHONE 9 9 7.45 $186.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 14 21.38 $1069.05 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 5 2.25 $56.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 63 72 76.65 $3832.40 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 7.58 $189.58 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 6.50 $477.23 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 8.00 $400.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.57 $114.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 163 182 1252.55 $62627.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 2.27 $113.33 $50.00
INTR -INTR INTERPRETER 11 13 38.37 $1918.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 115 126 869.80 $59042.07 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 68.25 $3707.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 72 80 460.48 $31257.08 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 40.32 $2190.26 $54.32
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 7 7 5.53 $103.59 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 14.07 $703.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 188 1185.95 $80502.18 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 13.00 $706.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 58.39 $770.78 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 256 356 25125.17 $12562.58 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 408 1247 29463.09 $275833.45 $9.36
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Total 1564 29800.74 $295342.94 $9.91
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Number of Children (Unduplicated) With at Least One Authorization 488