Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 2 2 2.00 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 74 80 78.27 $4696.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 32 32 38.00 $4544.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
NURS -NURS NURSING ASSESSMENT 4 4 2.80 $140.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 62 65 66.29 $3214.86 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 8.33 $404.17 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 29 29.00 $1406.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 105 109 123.43 $5986.29 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 248 344 364.11 $21750.71 $59.74
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 5.27 $263.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.10 $205.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 1.03 $25.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 112 117 196.80 $9839.89 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 3.45 $86.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 69 118.89 $5944.32 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.47 $111.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 32.92 $1645.83 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 109 154.11 $7705.52 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.18 $79.59 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 9.86 $492.86 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.00 $50.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 240 1813.35 $90667.37 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.33 $116.67 $50.00
INTR -INTR INTERPRETER 14 15 107.96 $5398.22 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 148 159 1136.66 $77156.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 19 20 94.71 $5144.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 69 73 403.03 $27357.41 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 46.61 $2531.70 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 17.00 $17.00 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5264 EARMOLD 3 3 2.89 $54.08 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 8.60 $430.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 191 204 1456.09 $98839.53 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.57 $465.60 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 21 21 155.66 $2054.71 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 371 532 56136.95 $28068.48 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.71 $185.72 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 500 1644 61937.20 $370466.19 $5.98
-----------------------------------------------------------------------------------------------------------------------------
Total 1990 62303.32 $392216.90 $6.30
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 528