Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 01/01/09 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
--------------------------------------------------------------------
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 4 4 3.39 $203.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 6.93 $346.43 $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 8 8 15.00 $1125.00 $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 2 2 4.00 $300.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 11 20.00 $1500.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 13.00 $630.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 13.14 $637.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 15 15.00 $727.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 51 80 116.46 $6875.16 $59.03
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 5 24.14 $1207.14 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.50 $75.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 93 96 147.26 $7362.86 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.50 $37.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 59 59 84.11 $4205.36 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 57 90.62 $4531.07 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 86 125.71 $6285.51 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.00 $150.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 8.71 $639.80 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 97.14 $4857.14 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.86 $96.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 135 137 1059.75 $52987.38 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 3.57 $178.33 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 12.49 $624.61 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 83 83 524.06 $35573.34 $67.88
PHY -97110 PT SESSION BY LICENSED PT 85 87 754.60 $51222.17 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5264 EARMOLD 4 4 2.41 $45.14 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.57 $228.33 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 137 145 1093.58 $74232.30 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 9.43 $124.46 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 27.29 $1364.29 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 273 788 4089.79 $247666.64 $60.56
-----------------------------------------------------------------------------------------------------------------------------
Total 869 4207.25 $254578.80 $60.51
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 282