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: 10/01/08 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.19 $7.19 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.19 $7.19 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 2 2.00 $32.60 $16.30
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 6.04 $362.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 4.00 $500.00 $125.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 84 127 220.00 $16500.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 6.00 $436.68 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 7.34 $355.94 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 60 68.09 $3302.51 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 11 10.11 $490.12 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 50 52 45.93 $2227.62 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 152 154 155.87 $7559.54 $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) 323 432 533.38 $32270.77 $60.50
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 14.13 $706.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 11 16.88 $844.05 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.75 $68.75 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 5 8.83 $441.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 15.47 $773.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 1.97 $49.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 9.68 $484.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.17 $54.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 12.15 $607.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.58 $39.58 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 6 6 85.71 $1071.43 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 9.14 $228.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 300 327 1905.82 $95290.83 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 13.03 $651.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 84 85 542.03 $36793.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 31 34 180.10 $9783.29 $54.32
PHY -97110 PT SESSION BY LICENSED PT 94 99 655.04 $44464.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 39 40 239.58 $13014.03 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 16.88 $16.88 $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 3.00 $1500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5264 EARMOLD 5 5 11.09 $207.58 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 252 268 1774.21 $120433.22 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 8.79 $477.24 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 59 61 483.64 $6384.09 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.29 $14.29 $50.00
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Subtotal (Total Children Is Unduplicated) 650 1020 6020.98 $342179.72 $56.83
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Total 1453 6554.55 $374457.68 $57.13
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Number of Children (Unduplicated) With at Least One Authorization 813