Summary Report for FSPSAs Ending During the Report Period Center: 06
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 27 27 27.93 $1033.41 $37.00
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Subtotal (Total Children Is Unduplicated) 27 27 27.93 $1033.41 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.00 $145.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 19 91.85 $5510.77 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 18 21.31 $997.10 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 18 40.39 $4830.98 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 26.29 $3285.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 362 448 582.43 $29121.43 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 29 29.00 $1406.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 16 16.00 $776.00 $48.50
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Subtotal (Total Children Is Unduplicated) 426 564 820.26 $46560.49 $56.76
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 39 47 49.71 $74571.45 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 40 56 203.81 $10190.59 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 183 232 288.43 $14421.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 8 11 11.00 $275.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 70 94 190.92 $9546.20 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 12 24.32 $607.98 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 137 272.07 $13603.38 $50.00
CONOP -CONOP CONSULT, OT, PHONE 15 17 31.14 $778.58 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 89 153.01 $7650.64 $50.00
CONPP -CONPP CONSULT, PT, PHONE 12 15 23.07 $576.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 128 250.39 $12519.53 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 27 33 67.05 $1676.37 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 32 32 785.86 $19646.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 103 146 4006.05 $100151.19 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 72.14 $3607.15 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 147 149 1625.70 $81284.75 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 32.86 $821.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 620 964 16725.22 $836261.20 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 16.90 $845.00 $50.00
INTR -INTR INTERPRETER 61 83 537.54 $26876.78 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 580 1077 10638.33 $722130.17 $67.88
OCCT -97530HM OT SESSION BY OT ASST 42 50 347.00 $18848.77 $54.32
PHY -97110 PT SESSION BY LICENSED PT 640 1161 12482.22 $847293.07 $67.88
PHY -97110HM PT SESSION BY PT ASST 25 25 105.95 $5755.39 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 19 22.23 $22.23 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 12 12 11.50 $5750.00 $500.00
SENS -V5264 EARMOLD 15 15 23.28 $435.82 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1255 2275 28383.41 $1926665.60 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 15 17 122.53 $6655.74 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 45 49 520.93 $6876.26 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 21 45 66.67 $6666.69 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 2.00 $1.00 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 13 13 76.00 $3800.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 24 36 729.81 $36490.73 $50.00
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Subtotal (Total Children Is Unduplicated) 1755 7046 78899.05 $4803303.19 $60.88
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Total 7637 79747.24 $4850897.08 $60.83
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Number of Children (Unduplicated) With at Least One Authorization 1765