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: 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 10.29 $380.57 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 10.29 $380.57 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 83 87 85.01 $5100.53 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 35 38 42.86 $5125.71 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 3.00 $375.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 2 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.00 $75.00 $75.00
NURS -NURS NURSING ASSESSMENT 4 4 9.60 $480.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 12.00 $582.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 74 76 86.29 $4184.86 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 6.77 $328.19 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 26 26.00 $1261.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 133 141 171.43 $8314.29 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 2.00 $200.00 $100.00
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Subtotal (Total Children Is Unduplicated) 276 403 451.95 $26481.17 $58.59
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 11.64 $581.99 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 14.11 $705.48 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.67 $66.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 123 126 204.43 $10221.29 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 11.03 $275.84 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 66 90.13 $4506.66 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.13 $53.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 28 29.10 $1455.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 116 163.95 $8197.26 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.73 $168.34 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 40.00 $500.00 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.14 $457.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 237 1797.85 $89892.36 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.73 $36.67 $50.00
INTR -INTR INTERPRETER 12 12 91.54 $4576.79 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 148 155 1120.08 $76030.92 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 58.97 $3203.07 $54.32
PHY -97110 PT SESSION BY LICENSED PT 88 106 512.87 $34813.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 27.75 $1507.38 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 23 23 21.32 $21.32 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 4 4 4.19 $78.42 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 6.56 $328.10 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 212 231 1473.71 $100035.38 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 65.12 $859.57 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 395 569 112939.12 $56469.56 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 32.71 $1635.72 $50.00
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Subtotal (Total Children Is Unduplicated) 522 1741 118739.59 $397678.09 $3.35
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Total 2145 119201.82 $424539.83 $3.56
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Number of Children (Unduplicated) With at Least One Authorization 578