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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 14.64 $541.79 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 14.64 $541.79 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 7 8.00 $388.00 $48.50
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
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 2.00 $43.58 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 2.00 $108.76 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 41 42 42.00 $2520.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 12.00 $1435.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 8 10 14.00 $700.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 65 68 96.46 $4823.22 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 35.00 $2625.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 10 15.50 $1162.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 32.50 $1803.75 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 350 353 499.50 $37462.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 31 31 42.00 $3150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 99 99 152.50 $11437.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 300 302 423.00 $23476.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 326 335 454.00 $34050.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 12 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 10.00 $485.00 $48.50
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Subtotal (Total Children Is Unduplicated) 686 1363 1882.46 $127841.29 $67.91
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 16 16.00 $24000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 23.91 $1195.48 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 72 81 104.33 $5216.44 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 20 20 9.59 $239.70 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 15 16.75 $837.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 12 23.66 $591.61 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 5.73 $286.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.29 $107.14 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 15.08 $754.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 8 9.45 $236.13 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 25.92 $1296.19 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 29 30 27.85 $696.19 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 41 898.67 $22466.79 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 18.64 $932.14 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 384 2029.99 $101499.28 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 14.06 $702.86 $50.00
INTR -INTR INTERPRETER 40 42 208.88 $10444.06 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 82 87 555.88 $37733.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 12.57 $682.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 146 157 961.68 $65278.89 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 40.86 $2219.36 $54.32
RSPT -RSPT RESPITE 2 2 70.93 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 35 36 40.70 $40.70 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 9 9 16.59 $310.51 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 13.57 $678.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 486 509 3322.33 $225519.59 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 32 32 275.83 $3640.97 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.71 $971.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 810 1246 6030.77 $3015.38 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 37.14 $1857.15 $50.00
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Subtotal (Total Children Is Unduplicated) 979 2804 14849.37 $516159.62 $34.76
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Total 4171 16746.47 $644542.69 $38.49
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Number of Children (Unduplicated) With at Least One Authorization 1148