Summary Report for FSPSAs Ending During the Report Period Center: 52
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 3.79 $103.07 $27.23
Screening, Eval, and Assessment, Class # 02
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 11 10.70 $642.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 7.00 $837.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 7.00 $875.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 35 42 42.00 $2100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 168 221 237.43 $11515.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 67 86 86.00 $4171.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 37 37 37.00 $1850.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 236 286 303.86 $14737.07 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 433 709 746.99 $37464.79 $50.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 18 21.00 $31500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 16 28.03 $1401.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 10.35 $517.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 147 202 594.12 $29705.86 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 116 298.66 $14932.76 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 106 298.36 $14918.21 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 162 236 625.67 $31283.35 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 17.17 $429.29 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 47 47 447.62 $22381.18 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 56.71 $1417.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 333 581 6700.55 $335027.37 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 26.14 $1307.15 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 191 305 3797.50 $257774.25 $67.88
PHY -97110 PT SESSION BY LICENSED PT 220 381 3968.54 $269384.69 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 8.94 $485.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 2.82 $2.82 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 5.00 $2500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 4 5 12.21 $228.59 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 9.57 $478.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 556 964 9319.51 $632608.29 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 39 43 450.97 $5952.83 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 548 1142 1073459.55 $536729.77 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 30.36 $1518.22 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 20 121.96 $6097.86 $50.00
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Subtotal (Total Children Is Unduplicated) 836 4213 1100316.62 $2199190.45 $2.00
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Total 4924 1101067.40 $2236758.31 $2.03
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Number of Children (Unduplicated) With at Least One Authorization 878