Summary Report for FSPSAs Initiated During the Report Period Center: 51
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 6 6 34.90 $1291.30 $37.00
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Subtotal (Total Children Is Unduplicated) 6 6 34.90 $1291.30 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 25 28 60.03 $3601.60 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 39.98 $4781.34 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 10.00 $1250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 17 18 66.29 $3314.29 $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 4 4 4.00 $194.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 41 42 129.14 $6263.43 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 37 38 38.00 $1843.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 75 82 274.00 $13289.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 10 12 14.00 $700.00 $50.00
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Subtotal (Total Children Is Unduplicated) 244 430 889.72 $53605.94 $60.25
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 8.40 $12600.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 5.87 $403.98 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 18 22 131.27 $6563.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.50 $125.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 222 287 705.78 $35288.85 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 141 178 353.89 $17694.45 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.06 $101.60 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 131 165 336.07 $16803.68 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 15.83 $395.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 192 233 392.87 $19643.27 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 6 36.43 $2674.59 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 10 826.86 $20671.43 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 528.29 $26414.29 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 66.00 $1650.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 316 410 8601.21 $430060.44 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 6 62.54 $3127.14 $50.00
INTR -INTR INTERPRETER 1 1 26.14 $1307.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 236 337 6540.09 $443941.32 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 331.57 $18010.70 $54.32
PHY -97110 PT SESSION BY LICENSED PT 227 323 6846.47 $464738.52 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 14 326.45 $17732.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 4 5 10.32 $193.23 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 13 98.79 $4939.53 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 414 581 10704.65 $726631.46 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 11.14 $605.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 278.29 $3673.37 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 89 132 162918.50 $81459.25 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 14 163.07 $8153.35 $50.00
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Subtotal (Total Children Is Unduplicated) 696 2799 200343.32 $2368054.93 $11.82
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Total 3235 201267.94 $2422952.17 $12.04
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Number of Children (Unduplicated) With at Least One Authorization 745