Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.75 $27.75 $37.00
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Subtotal (Total Children Is Unduplicated) 1 2 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 14.00 $679.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 28 28 29.18 $1750.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 10.00 $1196.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 11.25 $562.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 42 46 64.04 $3201.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.50 $187.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.50 $83.25 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 19 19 25.86 $1939.28 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 12.00 $900.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 25 25 32.00 $2400.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 46 61.36 $3405.32 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 9.50 $527.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 287 287 384.57 $28842.86 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 26.50 $1987.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 76 78 127.00 $9525.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 277 284 393.07 $21815.47 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 271 300 409.71 $30728.57 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 19.29 $935.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 24.57 $1191.71 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 26 26.00 $1261.00 $48.50
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Subtotal (Total Children Is Unduplicated) 662 1267 1701.89 $113869.72 $66.91
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 40 46.00 $69000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 18 19 43.98 $2198.81 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 60 62 75.35 $3767.39 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 11 13 9.13 $228.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 18 17.97 $898.33 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 17 18 39.72 $993.10 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 1.67 $83.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.13 $3.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 5.67 $283.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 7 18.53 $463.22 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 26.43 $1321.42 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 40 43 47.86 $1196.38 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 32 32 228.50 $5712.50 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 11 13 113.29 $5664.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 279 292 1669.36 $83467.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 21.29 $1064.29 $50.00
INTR -INTR INTERPRETER 18 18 81.34 $4067.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 77 84 589.55 $40018.50 $67.88
OCCT -97530HM OT SESSION BY OT ASST 9 9 45.50 $2471.55 $54.32
PHY -97110 PT SESSION BY LICENSED PT 153 169 1167.62 $79258.04 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 11 58.19 $3160.90 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 9.87 $9.87 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 5.00 $2500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 11 12 24.00 $449.28 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 3.00 $150.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 477 523 3415.14 $231819.90 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 18.57 $1008.80 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 138.29 $1825.37 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 15.00 $1500.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 649 961 5120.48 $2560.24 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 11.00 $550.00 $50.00
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Subtotal (Total Children Is Unduplicated) 843 2415 13072.41 $551538.58 $42.19
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Total 3684 14775.30 $665445.31 $45.04
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Number of Children (Unduplicated) With at Least One Authorization 1048