Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 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 1.18 $43.58 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.18 $43.58 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 6.00 $360.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 7 29.79 $3723.23 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 8.03 $401.67 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.50 $83.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 85 112 178.71 $13403.57 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 6.30 $305.55 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 34 33.29 $1614.51 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 5.79 $281.03 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 37 38 31.78 $1541.22 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 123 127 116.08 $5629.97 $48.50
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Subtotal (Total Children Is Unduplicated) 260 358 435.28 $28817.13 $66.20
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 5.27 $263.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.83 $45.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 7.03 $351.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.37 $9.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 5.25 $262.50 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 6.43 $321.25 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.92 $72.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 13 15.51 $775.42 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.92 $72.92 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 74.43 $930.36 $12.50
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 3.57 $178.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 238 246 1383.38 $69168.96 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 7.29 $364.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 56 61 430.36 $29212.63 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 15 85.50 $4644.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 55 362.90 $24633.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 24 25 178.42 $9691.72 $54.32
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $86.00 $43.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 174 186 1340.57 $90997.60 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 67 71 495.85 $6545.25 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 14.30 $715.24 $50.00
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Subtotal (Total Children Is Unduplicated) 491 715 4431.08 $244993.30 $55.29
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Total 1074 4867.53 $273854.01 $56.26
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Number of Children (Unduplicated) With at Least One Authorization 631