Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 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 21 21 27.08 $1001.85 $37.00
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Subtotal (Total Children Is Unduplicated) 21 21 27.08 $1001.85 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 18 111.17 $6670.25 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 22 28 32.66 $1528.28 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 23 25 42.11 $5036.01 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 353 427 552.43 $27621.43 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 25 25.00 $1212.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 14.00 $679.00 $48.50
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Subtotal (Total Children Is Unduplicated) 416 549 789.36 $43483.97 $55.09
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 49 51.71 $77571.45 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 51 71 207.83 $10391.39 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 178 226 305.43 $15271.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 12 12.00 $300.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 74 88 277.08 $13854.18 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 17 32.87 $821.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 140 172 444.61 $22230.64 $50.00
CONOP -CONOP CONSULT, OT, PHONE 23 30 56.07 $1401.70 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 101 278.41 $13920.75 $50.00
CONPP -CONPP CONSULT, PT, PHONE 16 23 32.78 $819.58 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 142 159 453.41 $22670.64 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 27 38 67.12 $1678.04 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 140 190 5028.57 $125714.30 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 672 1058 17089.85 $854492.28 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 9.10 $455.00 $50.00
INTR -INTR INTERPRETER 61 80 488.75 $24437.51 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 519 890 9057.86 $614847.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 20 30 374.68 $20352.42 $54.32
PHY -97110 PT SESSION BY LICENSED PT 577 1034 11203.94 $760523.17 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 51.77 $2811.90 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 28 33 36.23 $36.23 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 17 19 18.50 $9250.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 20 23 13.63 $255.21 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1297 2240 27562.26 $1870926.06 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 8 108.96 $5918.94 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 31 38 479.71 $6332.23 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 20 41 60.87 $6086.69 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 2.00 $1.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 24 36 689.86 $34492.75 $50.00
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Subtotal (Total Children Is Unduplicated) 1824 6720 74497.87 $4518167.03 $60.65
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Total 7290 75314.31 $4562652.85 $60.58
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Number of Children (Unduplicated) With at Least One Authorization 1842