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: 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 2 2 14.57 $539.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 1.82 $67.39 $37.00
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Subtotal (Total Children Is Unduplicated) 5 7 16.68 $617.10 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 46 53 54.00 $2619.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 4.00 $144.28 $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 59 62 70.08 $4204.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 16 19.29 $902.72 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 37 38 55.00 $6578.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 30 32 43.50 $2175.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 119 126 175.07 $8753.58 $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 1079 1091 1487.07 $111530.37 $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 983 996 1378.93 $76530.55 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1136 1226 1690.71 $126803.58 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 37 38 123.00 $5965.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 104 108 141.71 $6873.14 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 68 71 79.14 $3838.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 102 106 137.48 $6667.59 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 307 325 438.17 $21251.08 $48.50
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Subtotal (Total Children Is Unduplicated) 2377 4978 6859.62 $452106.77 $65.91
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 119 179 199.14 $298714.35 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 51 61 225.06 $11253.11 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 213 240 307.36 $15367.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 42 52 103.03 $2575.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 54 101.30 $5064.89 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 43 51 259.89 $6497.31 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 15.40 $769.77 $50.00
CONOP -CONOP CONSULT, OT, PHONE 14 17 88.34 $2208.57 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 18 27.70 $1385.24 $50.00
CONPP -CONPP CONSULT, PT, PHONE 24 32 154.32 $3858.09 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 89 94 226.09 $11304.71 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 98 114 364.92 $9122.96 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 105.71 $1321.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 99 127 2262.14 $56553.56 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 12 16 275.71 $13785.73 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 834 1109 15563.73 $778186.39 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 30.71 $1535.72 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 8 152.71 $7635.72 $50.00
INTR -INTR INTERPRETER 48 64 954.18 $47708.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 273 392 6346.30 $430786.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 38 40 790.32 $42930.01 $54.32
PHY -97110 PT SESSION BY LICENSED PT 415 640 10736.63 $728802.73 $67.88
PHY -97110HM PT SESSION BY PT ASST 48 49 824.43 $44782.97 $54.32
RSPT -RSPT RESPITE 1 1 103.47 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 71 73 1186.45 $1186.45 $1.00
SENS -FM FM RECEIVER HEARING AID 6 6 7.00 $11550.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 10 10 18.00 $9000.00 $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 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 26 37 70.95 $1328.15 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 2 26.43 $1321.43 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 85.90 $4295.24 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 22.29 $1114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1319 2022 31221.07 $2119286.36 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 6 96.29 $5230.23 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 102 105 1617.21 $21347.22 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 5 6 86.43 $8642.86 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1797 3765 44919.65 $22459.81 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 145.14 $7257.14 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 15 235.71 $11785.73 $50.00
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Subtotal (Total Children Is Unduplicated) 2145 9431 119966.13 $4749455.89 $39.59
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Total 14416 126842.43 $5202179.77 $41.01
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Number of Children (Unduplicated) With at Least One Authorization 2695