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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 8.62 $517.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 3.71 $185.72 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 18 18 30.00 $2250.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 33.00 $2475.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 12 12.00 $582.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 20 20 19.43 $942.29 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.50 $75.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 65 103 130.27 $8260.21 $63.41
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 3.14 $216.42 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 28.50 $1425.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 96 103 157.52 $7875.90 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.50 $37.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 68 106.27 $5313.29 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.00 $75.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 66 86.66 $4333.06 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 104 109 158.00 $7899.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.50 $37.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 10.86 $797.13 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 133.00 $3325.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 277.43 $13871.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.57 $89.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 116 121 1103.18 $55158.96 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 24.02 $1201.04 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 94 99 664.24 $45088.83 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.00 $434.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 96 102 734.63 $49866.75 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 38.29 $2079.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 5 5 3.90 $73.01 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 2.71 $135.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 176 1348.81 $91556.92 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.29 $395.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 13.21 $174.43 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 4 23.71 $1185.72 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 272 892 4947.44 $293686.20 $59.36
-----------------------------------------------------------------------------------------------------------------------------
Total 995 5077.70 $301946.41 $59.47
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 299