Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 2 2 2.00 $97.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 82 82 78.72 $4723.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 7.27 $340.08 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 28 28 30.00 $3588.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 11.29 $1410.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 15 20.00 $970.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 63 67 67.00 $3249.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 20 20 20.00 $970.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 136 143 144.03 $6985.62 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 265 386 398.31 $23568.19 $59.17
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.14 $147.56 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 10 11 18.60 $930.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 22.32 $1116.19 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.47 $11.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 119 125 209.15 $10457.49 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 9 9 8.90 $222.51 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 59 66 101.90 $5095.22 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 4 4.83 $120.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 26 40.94 $2047.19 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.97 $74.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 130 132 187.84 $9392.15 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.71 $92.64 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 49.29 $616.07 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.86 $342.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 245 259 1816.85 $90842.43 $50.00
INTR -INTR INTERPRETER 10 10 69.45 $3472.38 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 131 141 1161.76 $78860.39 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 47.97 $2605.55 $54.32
PHY -97110 PT SESSION BY LICENSED PT 86 94 557.79 $37862.83 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 10 97.75 $5309.77 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 19.92 $19.92 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 6 6 6.58 $123.14 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 33.90 $1695.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 248 265 1720.04 $116756.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 55.71 $735.43 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 442 677 240133.04 $120066.52 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 21.43 $1071.43 $50.00
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Subtotal (Total Children Is Unduplicated) 566 1900 246406.12 $491825.20 $2.00
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Total 2286 246804.42 $515393.39 $2.09
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Number of Children (Unduplicated) With at Least One Authorization 580