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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $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 17 17 16.07 $779.24 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 31 31.00 $1503.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.00 $727.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 69 70.38 $3413.52 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.00 $600.00 $100.00
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Subtotal (Total Children Is Unduplicated) 105 146 157.59 $8564.31 $54.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.17 $108.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 4.67 $233.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.77 $19.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.53 $276.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.96 $23.96 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 41 41 333.70 $16684.77 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.14 $7.15 $50.00
INTR -INTR INTERPRETER 1 2 12.14 $607.14 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 85 86 594.13 $40329.78 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 21.21 $1152.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 50 50 326.39 $22155.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 12.36 $671.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 0.17 $0.17 $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 1 1 2.27 $42.43 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 61.14 $3057.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 144 151 1067.96 $72493.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 83.86 $1106.91 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 120 148 11208.84 $5604.42 $0.50
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Subtotal (Total Children Is Unduplicated) 242 529 13746.41 $170598.18 $12.41
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Total 675 13904.00 $179162.50 $12.89
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Number of Children (Unduplicated) With at Least One Authorization 260