Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
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 7 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 2 2 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 6.14 $767.86 $125.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 72 88 86.03 $4172.62 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 136 149 149.00 $7226.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 35 45 43.90 $2129.15 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 89 100 99.86 $4843.26 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 297 376 377.99 $18332.38 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.00 $600.00 $100.00
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Subtotal (Total Children Is Unduplicated) 379 774 783.92 $39104.48 $49.88
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.17 $208.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 15 38.86 $1942.86 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 12.82 $641.19 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 13.62 $681.19 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.77 $19.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 17.18 $859.05 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 5 16.81 $840.71 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 5 15.71 $392.86 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 1452.29 $36307.14 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 8.43 $421.43 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 156.43 $7821.43 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.86 $292.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 111 160 2675.48 $133774.03 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 1.14 $57.15 $50.00
INTR -INTR INTERPRETER 1 2 12.14 $607.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 304 444 7419.60 $503642.19 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 14 162.93 $8850.29 $54.32
PHY -97110 PT SESSION BY LICENSED PT 169 255 3942.20 $267596.42 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 11 71.44 $3880.69 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 6.30 $6.30 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 5.27 $98.59 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 87.57 $4378.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 513 717 11367.07 $771596.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 27 27 271.07 $3578.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 226 339 40835.65 $20417.82 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 7 77.00 $3850.01 $50.00
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Subtotal (Total Children Is Unduplicated) 667 2054 68689.80 $1786236.21 $26.00
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Total 2828 69473.73 $1825340.68 $26.27
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Number of Children (Unduplicated) With at Least One Authorization 709