Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
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 8 8 7.70 $462.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 7.00 $837.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 11.00 $1375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 40 48 48.00 $2400.00 $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 183 243 259.43 $12582.29 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 75 96 96.00 $4656.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 40 40 40.00 $2000.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 261 325 330.33 $16020.94 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 473 793 820.46 $41292.99 $50.33
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 20 23.00 $34500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 16 32.23 $1611.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 8.45 $422.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 170 252 728.09 $36404.49 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 126 335.34 $16766.79 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 118 350.04 $17502.12 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 181 271 731.50 $36574.94 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 16.65 $416.37 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 11.43 $571.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 5 62.29 $1557.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 363 691 7475.15 $373757.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 42.29 $2114.29 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 198 323 4103.72 $278560.58 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.11 $168.78 $54.32
PHY -97110 PT SESSION BY LICENSED PT 219 384 4314.43 $292863.72 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 7.65 $415.80 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 5.61 $5.61 $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 8 20.70 $387.50 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 29.71 $1485.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 592 1050 9757.77 $662357.71 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 25 30 397.15 $5242.38 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 716 1730 1502329.63 $751164.81 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 20 32 159.15 $7957.62 $50.00
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Subtotal (Total Children Is Unduplicated) 894 5086 1530955.40 $2525916.11 $1.65
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Total 5881 1531779.64 $2567312.18 $1.68
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Number of Children (Unduplicated) With at Least One Authorization 923