Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.52 $4.61 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.52 $5.64 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.52 $11.38 $21.79
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.52 $14.77 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 3 3.00 $180.00 $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 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 13 13 13.00 $650.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 79 93 93.00 $4510.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 30 30.00 $1455.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 29 29 29.00 $1450.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 102 120 119.25 $5783.63 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 213 303 302.03 $15012.81 $49.71
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 23.13 $1156.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.77 $38.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 79 85 131.78 $6589.18 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 42 50.02 $2500.84 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 39 63.05 $3152.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 95 151.38 $7568.93 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 167 192 901.00 $45050.10 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.14 $657.15 $50.00
INTR -INTR INTERPRETER 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 85 89 460.01 $31225.31 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 5.07 $275.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 92 438.84 $29788.70 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 4.00 $217.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 2.31 $2.31 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 3 3 6.42 $120.22 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 13.86 $692.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 264 330 1359.05 $92252.27 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.71 $147.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 14.18 $187.16 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 368 557 187241.81 $93620.90 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 21.07 $1053.58 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 454 1558 190911.61 $321947.19 $1.69
-----------------------------------------------------------------------------------------------------------------------------
Total 1861 191213.64 $336960.01 $1.76
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 500