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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 13 18 19.00 $950.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 74 95 95.00 $4607.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 27 29 29.00 $1406.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 27 27.00 $1350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 120 149 148.23 $7189.32 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 221 325 325.23 $16046.20 $49.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 8 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.71 $85.72 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 93 102 120.07 $6003.34 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 58 71.13 $3556.66 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 37 50.17 $2508.33 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 104 141.24 $7062.03 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 159 195 831.05 $41552.60 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 14.57 $728.57 $50.00
INTR -INTR INTERPRETER 3 3 6.00 $300.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 94 102 585.07 $39714.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 12.54 $680.94 $54.32
PHY -97110 PT SESSION BY LICENSED PT 94 99 475.84 $32300.31 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 10 7.66 $7.66 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.57 $228.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 261 303 1314.08 $89199.88 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 25.00 $330.00 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 353 579 196989.87 $98494.94 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 11 27.08 $1353.81 $50.00
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Subtotal (Total Children Is Unduplicated) 434 1628 200692.65 $342257.99 $1.71
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Total 1953 201017.88 $358304.18 $1.78
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Number of Children (Unduplicated) With at Least One Authorization 494