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: 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 2.77 $102.37 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.77 $102.37 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 15.91 $954.58 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 4.14 $517.86 $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 9 9 8.17 $396.35 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 59 59 53.70 $2604.37 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 47 32.99 $1600.24 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 178 179 170.87 $8287.03 $48.50
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Subtotal (Total Children Is Unduplicated) 301 448 526.78 $32013.25 $60.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 14.87 $743.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 5.83 $291.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 12 18.81 $940.60 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.22 $5.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 23.26 $1163.10 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 8.97 $224.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 18.03 $901.43 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 6.32 $157.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 16.82 $840.83 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 12.56 $314.05 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 22.57 $282.14 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 3.86 $192.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.43 $110.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 246 254 1739.05 $86952.27 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 40.36 $2017.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 87 92 654.04 $44395.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 25 25 116.88 $6349.11 $54.32
PHY -97110 PT SESSION BY LICENSED PT 94 97 704.17 $47798.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 18 123.57 $6712.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 40.94 $40.94 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 6 6 10.54 $197.39 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 255 267 1988.91 $135007.05 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.71 $690.64 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 51 51 369.20 $4873.38 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 28.33 $1416.31 $50.00
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Subtotal (Total Children Is Unduplicated) 606 948 5995.24 $355920.57 $59.37
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Total 1397 6524.79 $388036.18 $59.47
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Number of Children (Unduplicated) With at Least One Authorization 648