Summary Report for FSPSAs Ending During the Report Period Center: 52
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 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $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 1.69 $201.99 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 7 8.00 $1000.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 3.00 $150.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 12 12 13.00 $650.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 60 77 77.00 $3734.50 $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 31 35 35.00 $1697.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 25 27 27.00 $1350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 94 102 102.00 $4947.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 202 270 274.69 $14116.93 $51.39
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 5 15.50 $775.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 3.38 $169.17 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 77 85 97.25 $4862.75 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 40 45.62 $2280.84 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.22 $5.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 39 43.88 $2194.16 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 91 101 115.50 $5774.83 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.14 $7.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 18.14 $453.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 151 181 818.90 $40945.17 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.43 $221.43 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 71 75 411.52 $27933.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.86 $155.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 85 93 340.37 $23104.17 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.57 $31.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 1.93 $1.93 $1.00
SENS -V5264 EARMOLD 2 3 7.38 $138.11 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 16.86 $842.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 278 333 1423.80 $96647.84 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 8.43 $111.26 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 342 503 173082.43 $86541.22 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 9 27.45 $1372.27 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 447 1485 176490.56 $296219.12 $1.68
-----------------------------------------------------------------------------------------------------------------------------
Total 1755 176765.25 $310336.05 $1.76
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 499