Summary Report for FSPSAs Ending During the Report Period Center: 54
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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 2 2.00 $37.00 $18.50
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 71 73 71.94 $4316.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 17 17 17.00 $2033.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 10 10.23 $496.32 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 46 48 53.57 $2598.21 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 12 12.00 $582.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 29 36.29 $1759.86 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 100 104 113.00 $5480.50 $48.50
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Subtotal (Total Children Is Unduplicated) 208 301 322.03 $17998.42 $55.89
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 7.56 $377.94 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 6.30 $315.01 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.27 $6.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 81 86 117.11 $5855.72 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.07 $51.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 60 75.80 $3789.97 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.13 $28.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 22.00 $1100.02 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.07 $26.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 76 117.68 $5884.05 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 3.67 $91.67 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 185 202 1409.71 $70485.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.00 $200.00 $50.00
INTR -INTR INTERPRETER 12 12 89.50 $4475.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 113 122 814.27 $55272.61 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 62.68 $3404.69 $54.32
PHY -97110 PT SESSION BY LICENSED PT 74 81 440.48 $29899.76 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 21.14 $1148.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 16.00 $16.00 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5264 EARMOLD 4 4 3.98 $74.46 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 14.57 $728.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 183 1216.93 $82605.11 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.71 $93.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 96.82 $1278.04 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 294 419 56340.22 $28170.11 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 9.00 $450.00 $50.00
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Subtotal (Total Children Is Unduplicated) 414 1338 60903.66 $301921.92 $4.96
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Total 1641 61227.70 $319957.34 $5.23
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Number of Children (Unduplicated) With at Least One Authorization 467