Summary Report for FSPSAs Ending During the Report Period Center: 51
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 9 9 39.80 $1472.60 $37.00
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Subtotal (Total Children Is Unduplicated) 9 9 39.80 $1472.60 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 22 22 54.32 $3258.94 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 22.14 $2648.29 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 8 8.00 $1000.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 17 17 41.49 $2074.29 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 52 52 64.14 $4810.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 17.00 $1275.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 20 20 28.00 $2100.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 12 13 18.00 $999.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 77 81 108.14 $8110.72 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 50 144.57 $7011.71 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 12 11.52 $558.83 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 33 35 35.00 $1697.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 72 77 138.43 $6713.78 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 10 13 16.57 $828.57 $50.00
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Subtotal (Total Children Is Unduplicated) 252 429 724.32 $44078.32 $60.85
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 8.02 $12033.30 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 5.87 $403.98 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 19 22 115.96 $5797.85 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 207 301 694.65 $34732.51 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 114 156 305.39 $15269.31 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.41 $85.27 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 110 151 326.80 $16340.06 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 15.83 $395.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 135 172 273.46 $13672.89 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 36.57 $2685.08 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 3 3 138.00 $3450.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 19 1683.86 $42096.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 240.00 $12000.00 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 75 76 397.06 $19853.09 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 71.00 $1775.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 302 408 8091.17 $404558.25 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 5 60.12 $3006.19 $50.00
INTR -INTR INTERPRETER 1 1 26.14 $1307.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 249 366 6857.63 $465496.14 $67.88
OCCT -97530HM OT SESSION BY OT ASST 18 18 445.39 $24193.62 $54.32
PHY -97110 PT SESSION BY LICENSED PT 231 345 7156.33 $485771.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 17 331.07 $17983.54 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 4 5 8.51 $159.33 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 11 117.46 $5872.87 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 396 594 10244.74 $695412.93 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 32.71 $1777.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 19 19 358.36 $4730.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 98 151 188197.93 $94098.96 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 9.57 $478.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 10 103.40 $5169.77 $50.00
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Subtotal (Total Children Is Unduplicated) 719 2892 226366.39 $2392331.86 $10.57
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Total 3330 227130.51 $2437882.77 $10.73
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Number of Children (Unduplicated) With at Least One Authorization 785