Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 9.32 $559.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.08 $487.70 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 5.21 $260.72 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 9.00 $675.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 8 14.00 $1050.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 17.14 $831.43 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 20 21 86.43 $4191.79 $48.50
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Subtotal (Total Children Is Unduplicated) 59 80 169.19 $9402.14 $55.57
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.66 $983.40 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 15.00 $750.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 92 95 172.29 $8614.68 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 55 84.69 $4234.40 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 55 80.62 $4030.83 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 73 112.05 $5602.26 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 3.00 $220.26 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 169.57 $8478.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 120 123 966.32 $48315.99 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 4.43 $221.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.57 $128.57 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 80 84 644.45 $43745.44 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.29 $124.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 87 643.37 $43672.00 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 10.86 $589.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 3 1.01 $18.93 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.00 $50.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 5 11.29 $564.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 130 138 1114.32 $75640.14 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 13.29 $175.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 7 19.43 $971.43 $50.00
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Subtotal (Total Children Is Unduplicated) 247 753 4081.99 $248295.62 $60.83
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Total 834 4252.17 $257734.76 $60.61
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Number of Children (Unduplicated) With at Least One Authorization 275