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: 10/01/08 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 1 1 0.08 $3.08 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.08 $3.08 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 14.77 $886.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 14 12.23 $572.26 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 12.18 $1457.12 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.00 $150.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 28 42 49.18 $3482.88 $70.82
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 12.71 $19071.45 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 22 22 27.50 $1374.88 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 31 36.00 $1800.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 4.00 $100.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 17 29.38 $1469.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 2.83 $70.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 45 55.10 $2755.23 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 6.38 $159.38 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 22 21.99 $1099.51 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 7 6.19 $154.79 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 42 56.87 $2843.69 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 15 18.55 $463.75 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 49 52 814.43 $20360.73 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 235 254 1454.92 $72746.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 2.03 $101.67 $50.00
INTR -INTR INTERPRETER 17 19 61.14 $3057.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 177 196 697.46 $47343.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 8.10 $440.25 $54.32
PHY -97110 PT SESSION BY LICENSED PT 235 252 1079.90 $73303.43 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 3.87 $210.10 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 13 12.20 $12.20 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 11 11 10.50 $5250.00 $500.00
SENS -V5264 EARMOLD 12 12 7.30 $136.66 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 523 594 3068.52 $208291.22 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 10.89 $591.70 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 108.14 $1427.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 3.10 $310.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 13 98.74 $4937.03 $50.00
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Subtotal (Total Children Is Unduplicated) 826 1667 7718.77 $469882.09 $60.88
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Total 1710 7768.03 $473368.05 $60.94
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Number of Children (Unduplicated) With at Least One Authorization 831