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: 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 3 3 3.00 $180.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.90 $42.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 5.00 $625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 8 14.19 $709.29 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 16 16 26.00 $1950.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $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 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 17 29.00 $2175.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 19 19.00 $921.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.00 $727.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 18 29.57 $1434.21 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 3.50 $175.00 $50.00
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Subtotal (Total Children Is Unduplicated) 72 112 157.16 $9831.39 $62.56
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 8.86 $609.91 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 9.00 $619.74 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 4.79 $239.29 $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 100 106 181.32 $9065.88 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 48 64.62 $3230.84 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 64 101.27 $5063.69 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 113 158.68 $7934.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.00 $75.00 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 3.00 $220.26 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 99.00 $2475.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 241.14 $12057.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 126 130 924.04 $46202.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 3 9.14 $457.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 71 73 535.63 $36358.75 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 34.29 $1862.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 87 88 671.92 $45609.83 $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 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 2 0.59 $11.02 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 2 2 6.73 $336.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 3.43 $171.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 151 159 1138.87 $77306.34 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 39.43 $520.46 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 25.57 $1278.57 $50.00
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Subtotal (Total Children Is Unduplicated) 265 828 4268.82 $252781.90 $59.22
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Total 940 4425.98 $262613.29 $59.33
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Number of Children (Unduplicated) With at Least One Authorization 280