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: 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 -AUDE UNSPECIFIED AUDE SERVICES 59 59 58.11 $3486.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 10.00 $1196.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 8.43 $1053.58 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 30 33 39.00 $1950.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 4.00 $300.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 6 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 7.50 $416.25 $55.50
NURS -NURS NURSING ASSESSMENT 1 1 4.80 $240.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 11 11.00 $533.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 39 39.00 $1891.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 11 23.14 $1122.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.00 $533.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 86 91 90.57 $4392.71 $48.50
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Subtotal (Total Children Is Unduplicated) 213 295 327.05 $18612.63 $56.91
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 14.59 $729.61 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 8.22 $411.12 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 59 62 92.31 $4615.57 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 5.48 $136.95 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 45 67.41 $3370.49 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.67 $141.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 26.68 $1333.89 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.83 $20.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 114 171.87 $8593.61 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 7 4.62 $115.56 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 38.57 $482.14 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 237 256 2013.33 $100666.69 $50.00
INTR -INTR INTERPRETER 17 17 107.93 $5396.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 103 117 864.79 $58701.91 $67.88
OCCT -97530HM OT SESSION BY OT ASST 7 8 45.63 $2478.54 $54.32
PHY -97110 PT SESSION BY LICENSED PT 64 75 515.36 $34982.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 35.07 $1905.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 17.50 $17.50 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 5 5 6.59 $123.37 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 12 46.08 $2304.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 187 209 1619.58 $109937.33 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.36 $291.00 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 30.46 $402.13 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 401 652 273058.71 $136529.35 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 20.14 $1007.14 $50.00
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Subtotal (Total Children Is Unduplicated) 482 1653 278829.79 $477931.65 $1.71
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Total 1948 279156.85 $496544.27 $1.78
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Number of Children (Unduplicated) With at Least One Authorization 502