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: 01/01/09 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 3.66 $219.34 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.43 $553.58 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 16.57 $2071.44 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 54 72 101.50 $7612.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 46 48 47.84 $2320.11 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 35 37 26.75 $1297.37 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 166 169 173.80 $8429.42 $48.50
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Subtotal (Total Children Is Unduplicated) 277 365 408.05 $24282.61 $59.51
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 5.40 $8100.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 14.83 $741.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 7.75 $387.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.45 $61.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 10 10 11.14 $557.09 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.85 $46.25 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 9 7.87 $393.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 9.32 $232.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 13.66 $682.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.62 $90.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 17.52 $875.83 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 14.63 $365.84 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 36.43 $455.36 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 261 278 1535.20 $76759.93 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 19.60 $980.24 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 80 85 509.62 $34592.96 $67.88
OCCT -97530HM OT SESSION BY OT ASST 16 17 63.14 $3429.93 $54.32
PHY -97110 PT SESSION BY LICENSED PT 86 91 555.78 $37726.44 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 21 91.78 $4985.56 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 19 18.93 $18.93 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5264 EARMOLD 4 4 7.62 $142.69 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 243 260 1812.22 $123013.49 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 4.57 $248.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 56 57 295.86 $3905.32 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 4.43 $221.43 $50.00
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Subtotal (Total Children Is Unduplicated) 582 924 5066.22 $300665.58 $59.35
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Total 1290 5475.27 $324985.19 $59.36
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Number of Children (Unduplicated) With at Least One Authorization 721