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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.70 $102.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 10 13 13.00 $650.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 53 68 75.71 $3672.14 $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 18 21 21.00 $1018.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 8 8 8.00 $400.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 84 92 97.33 $4720.44 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 160 216 230.74 $11594.12 $50.25
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 5 9.40 $470.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.47 $23.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 75 88 128.37 $6418.32 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 33 40.23 $2011.66 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 41 53.33 $2666.66 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 91 135.01 $6750.28 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.28 $57.08 $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 3 14.29 $357.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 146 181 875.23 $43761.70 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 74 82 510.98 $34685.60 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.11 $168.78 $54.32
PHY -97110 PT SESSION BY LICENSED PT 83 90 449.50 $30512.32 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 5.61 $5.61 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 2 3 4.70 $87.98 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 20.14 $1007.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 258 298 1293.24 $87785.24 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 12.36 $163.12 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 320 460 181486.43 $90743.22 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 11 23.39 $1169.52 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 417 1405 185084.51 $313016.14 $1.69
-----------------------------------------------------------------------------------------------------------------------------
Total 1622 185316.25 $324610.26 $1.75
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 449