Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 7.41 $444.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 5 5 29.65 $3705.95 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 9.00 $450.00 $50.00
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 86 113 180.21 $13516.07 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 56 57 62.08 $3010.92 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 49 50 42.73 $2072.57 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 164 169 153.48 $7443.98 $48.50
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Subtotal (Total Children Is Unduplicated) 296 435 518.07 $32881.01 $63.47
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 12.63 $631.67 $50.00
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 0.80 $20.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 4.79 $239.58 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.60 $40.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 18.03 $901.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 4.65 $116.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 12.24 $612.08 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.13 $78.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 20 23.92 $1195.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 7 7 3.47 $86.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 47.57 $594.64 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 275 286 1618.95 $80947.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 17.40 $869.76 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 81 83 511.94 $34750.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 16 106.79 $5800.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 85 87 621.12 $42161.55 $67.88
PHY -97110HM PT SESSION BY PT ASST 20 21 126.35 $6863.33 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 4.00 $172.00 $43.00
SENS -V5264 EARMOLD 3 3 7.56 $141.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 247 266 1870.69 $126982.31 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 25.14 $1365.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 59 60 448.21 $5916.43 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 8.86 $442.86 $50.00
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Subtotal (Total Children Is Unduplicated) 613 919 5516.10 $319347.04 $57.89
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Total 1355 6035.17 $352265.05 $58.37
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Number of Children (Unduplicated) With at Least One Authorization 654