Summary Report for FSPSAs Ending During the Report Period Center: 55
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
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.34 $280.39 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.14 $517.86 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 22 22 20.79 $1008.26 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 28 35.86 $1739.07 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 14 14.00 $679.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 12 14.14 $685.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 73 96.02 $4656.81 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 7.14 $714.29 $100.00
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Subtotal (Total Children Is Unduplicated) 110 157 200.44 $10642.62 $53.10
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 12 12.00 $600.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.51 $25.42 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 2 1.07 $26.67 $25.00
CONOP -CONOP CONSULT, OT, PHONE 1 2 1.07 $26.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 6.09 $304.29 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.37 $68.34 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 804.57 $20114.29 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 20.86 $1042.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 44 47 255.15 $12757.40 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 13.77 $688.57 $50.00
INTR -INTR INTERPRETER 3 3 12.43 $621.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 107 114 507.57 $34453.91 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 33.86 $1839.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 55 268.47 $18223.99 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 2.14 $116.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.33 $1.33 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 1 1 1.82 $34.11 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 46.29 $2314.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 173 185 972.00 $65979.42 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 43.86 $578.92 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 149 190 2159.16 $1079.58 $0.50
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Subtotal (Total Children Is Unduplicated) 277 650 5175.37 $164071.21 $31.70
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Total 807 5375.81 $174713.82 $32.50
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Number of Children (Unduplicated) With at Least One Authorization 306