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: 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 1 1 4.07 $150.47 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.02 $37.82 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 5.09 $188.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 3 3.00 $48.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.00 $54.20 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.00 $21.60 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 19 22.09 $1325.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 10 12.00 $1435.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.86 $732.14 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 15 16 256.50 $32062.53 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 38 38 44.51 $2225.56 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 7.81 $433.52 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 5.00 $375.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 3.00 $225.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 7.50 $562.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 11 20.50 $1137.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 288 404 659.35 $49451.07 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 9 10 12.00 $873.36 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 3 3 3.00 $450.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.77 $88.34 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 29 33 30.22 $1465.51 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 197 208 239.81 $11630.68 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 34 39 41.93 $2033.46 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 176 194 227.63 $11040.18 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 500 581 599.44 $29072.90 $48.50
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 919 1603 2218.91 $147247.09 $66.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 29 31 54.73 $2736.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 39 62.48 $3124.01 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 10 11 29.42 $735.60 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 35 38 64.33 $3216.25 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 13.43 $335.78 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 27 67.77 $3388.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 8 19.10 $477.44 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 27 65.74 $3287.08 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 7 26.76 $669.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 48 93.59 $4679.47 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 14 33.95 $848.72 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 23 32 2074.00 $25925.00 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 3.29 $82.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 19.57 $489.29 $25.00
EIIF -90812 INDIVIDUAL PSYCHOTHERAPY, 45-50 MIN 1 1 3.77 $188.34 $50.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 132.86 $6642.86 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 233 239 1978.09 $98904.41 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 52.71 $1317.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 680 912 15208.18 $760409.16 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 12 12 194.00 $9700.00 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 22 23 324.72 $16235.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 183 248 3968.67 $269393.30 $67.88
OCCT -97530HM OT SESSION BY OT ASST 105 122 1850.48 $100518.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 201 285 4812.03 $326640.41 $67.88
PHY -97110HM PT SESSION BY PT ASST 137 165 2558.21 $138962.06 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 36.60 $36.60 $1.00
SENS -FM FM RECEIVER HEARING AID 5 5 8.43 $13907.19 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 12.00 $6000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 4.00 $260.00 $65.00
SENS -V5264 EARMOLD 12 14 35.19 $658.76 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 5.00 $250.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 566 823 13558.20 $920330.60 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 15 15 94.36 $5125.48 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 269 335 5514.11 $72786.22 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3 3 40.00 $20.00 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 4 4 42.29 $2114.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 105.09 $5254.29 $50.00
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Subtotal (Total Children Is Unduplicated) 1519 3541 53179.12 $2823650.57 $53.10
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Total 5146 55403.12 $2971085.96 $53.63
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Number of Children (Unduplicated) With at Least One Authorization 1776