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: 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 3 3 4.79 $177.19 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 8.86 $327.66 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 3 3.00 $48.90 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $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 21 21 34.39 $2063.24 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 8.00 $956.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 14 15 209.64 $26205.39 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 39 39 45.51 $2275.56 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.00 $333.00 $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 289 405 660.85 $49563.57 $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 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 26 33 31.56 $1530.71 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 217 235 247.66 $12011.56 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 31 37 43.10 $2090.31 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 189 208 239.24 $11603.04 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 573 660 679.50 $32955.59 $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) 954 1717 2276.45 $145820.43 $64.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 17.00 $25500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 33 34 76.30 $3815.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 40 62.81 $3140.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 8 9 19.75 $493.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 34 36 69.85 $3492.69 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 12.18 $304.59 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 40 97.01 $4850.59 $50.00
CONOP -CONOP CONSULT, OT, PHONE 12 14 30.68 $767.09 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 37 100.30 $5014.76 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 11 29.64 $741.05 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 55 125.69 $6284.58 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 21 44.86 $1121.46 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 14 16 1170.86 $14635.71 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 136.71 $6835.71 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 57.14 $1428.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 822 1158 16957.20 $847859.78 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 20 25 366.68 $18334.06 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 228 305 4355.44 $295647.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 88 107 1507.83 $81905.13 $54.32
PHY -97110 PT SESSION BY LICENSED PT 238 335 5250.18 $356382.51 $67.88
PHY -97110HM PT SESSION BY PT ASST 94 113 1878.43 $102036.37 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 34 76.99 $76.99 $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 7 7 11.00 $5500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 4.00 $260.00 $65.00
SENS -V5264 EARMOLD 13 14 34.06 $637.52 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 694 986 15729.53 $1067720.55 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 105.50 $5730.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 244 279 4659.05 $61499.45 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3 3 40.00 $20.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 121.88 $6093.93 $50.00
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Subtotal (Total Children Is Unduplicated) 1623 3726 53153.56 $2934780.68 $55.21
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Total 5447 55438.86 $3080928.77 $55.57
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Number of Children (Unduplicated) With at Least One Authorization 1731