Summary Report for FSPSAs Ending During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 8 10 10.00 $600.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 15.00 $1794.00 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 71 84 83.17 $4033.85 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 137 157 157.00 $7614.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 34 40 39.17 $1899.85 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 97 112 112.00 $5432.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 272 352 350.96 $17021.34 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 365 774 771.30 $38694.45 $50.17
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 14.00 $21000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 15 38.86 $1942.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.56 $13.96 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 7.96 $397.86 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 21.47 $1073.45 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.56 $13.96 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 6 24.16 $1208.22 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 9 33.36 $1667.97 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 5 15.51 $387.65 $25.00
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 435.43 $10885.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 1452.29 $36307.14 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 23.43 $1171.43 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 134.43 $6721.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 22 23 184.39 $9219.59 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 91 128 2397.48 $119873.79 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 1 1 11.29 $564.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 1.14 $57.15 $50.00
INTR -INTR INTERPRETER 1 1 4.57 $228.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 316 474 7566.51 $513614.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 9 146.86 $7977.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 166 243 3601.84 $244492.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 30.18 $1639.17 $54.32
SENS -V5264 EARMOLD 3 4 5.00 $93.60 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 12.00 $600.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 26.43 $1321.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 491 707 10804.01 $733376.02 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 20 21 324.29 $4280.57 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 106 157 26728.61 $13364.30 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 3 3 22.71 $1135.72 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 55.57 $2778.58 $50.00
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Subtotal (Total Children Is Unduplicated) 626 1856 54124.86 $1737409.17 $32.10
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Total 2630 54896.16 $1776103.62 $32.35
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Number of Children (Unduplicated) With at Least One Authorization 658