Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 2 2 0.29 $10.57 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.00 $37.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 2.96 $109.68 $37.00
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Subtotal (Total Children Is Unduplicated) 5 7 4.25 $157.25 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 45 52 53.00 $2570.50 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.00 $10.62 $10.62
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.00 $8.44 $8.44
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 56 58 65.88 $3952.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 14 17.29 $809.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 38 38 52.00 $6219.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 31 33 49.68 $2483.93 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 117 124 173.07 $8653.58 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 15 15 21.50 $1612.50 $75.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 2 2 3.00 $166.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 82 85 115.41 $8655.84 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 13 13 21.00 $1575.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 86 88 115.00 $8625.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 144 155 207.41 $11511.32 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 11 11 14.50 $804.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1076 1088 1483.07 $111230.37 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 97 97 117.50 $8812.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 205 208 333.14 $24985.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 981 994 1375.93 $76364.05 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1135 1224 1688.71 $126653.58 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 56 59 132.71 $6436.64 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 112 116 149.71 $7261.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 98 103 148.71 $7212.64 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 128 132 207.76 $10076.44 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 392 423 642.36 $31154.37 $48.50
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Subtotal (Total Children Is Unduplicated) 2464 5146 7203.36 $468383.59 $65.02
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 116 174 193.14 $289714.35 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 42 48 146.70 $7334.77 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 214 242 331.75 $16587.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 47 57 116.18 $2904.41 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 52 97.69 $4884.29 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 29 33 164.56 $4113.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 31.20 $1560.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 12 13 75.97 $1899.29 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 14 25.97 $1298.57 $50.00
CONPP -CONPP CONSULT, PT, PHONE 17 20 97.97 $2449.16 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 74 223.04 $11151.96 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 74 82 311.48 $7787.00 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 105.71 $1321.43 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 19 20 308.86 $7721.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 78 94 1839.07 $45976.78 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 8 128.57 $6428.58 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 188 191 1695.66 $84783.19 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.57 $189.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 641 807 13150.48 $657523.92 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 2 39.29 $1964.29 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 2 2 2.00 $100.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 7 130.86 $6542.86 $50.00
INTR -INTR INTERPRETER 26 37 1023.46 $51173.23 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 266 392 6385.13 $433422.64 $67.88
OCCT -97530HM OT SESSION BY OT ASST 50 52 895.75 $48656.90 $54.32
PHY -97110 PT SESSION BY LICENSED PT 399 612 11113.40 $754377.36 $67.88
PHY -97110HM PT SESSION BY PT ASST 72 77 1279.79 $69517.98 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 886.36 $886.36 $1.00
SENS -FM FM RECEIVER HEARING AID 4 4 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 9 9 16.00 $8000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.73 $1359.48 $237.12
SENS -V5264 EARMOLD 22 31 58.00 $1085.76 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 2 26.43 $1321.43 $50.00
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 16.14 $807.15 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 6 69.56 $3478.10 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 2 2 25.14 $1257.14 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1154 1786 29691.24 $2015441.61 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 25 27 265.86 $14441.35 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 83 89 1536.93 $20287.46 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 5 75.14 $7514.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1707 3380 43408.31 $21704.14 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 153.71 $7685.71 $50.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 5 5 109.57 $5478.58 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 11 215.71 $10785.72 $50.00
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Subtotal (Total Children Is Unduplicated) 2047 8510 116592.55 $4649832.30 $39.88
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Total 13663 123800.16 $5118373.14 $41.34
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Number of Children (Unduplicated) With at Least One Authorization 2937