Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.00 $28.28 $28.28
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 15 14.16 $686.55 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 24 32.71 $1586.64 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 14 14.00 $679.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 10.00 $485.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 61 63 69.10 $3351.39 $48.50
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Subtotal (Total Children Is Unduplicated) 96 133 147.97 $7289.84 $49.27
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 5.67 $283.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.50 $225.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 1.78 $89.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.90 $22.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.10 $105.01 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.12 $27.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.32 $116.07 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.38 $69.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.22 $5.42 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 822.86 $20571.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 37 38 221.71 $11085.72 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 4.17 $208.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.71 $35.72 $50.00
INTR -INTR INTERPRETER 1 1 0.71 $35.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 88 90 493.16 $33475.95 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 60.36 $3278.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 57 59 315.19 $21395.12 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 52.00 $2824.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 3.03 $3.03 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 1.24 $23.30 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 16.71 $835.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 161 167 960.82 $65220.54 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.29 $450.08 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 92.36 $1219.11 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 141 181 1257.26 $628.63 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 8.57 $428.58 $50.00
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Subtotal (Total Children Is Unduplicated) 267 601 4342.15 $165163.84 $38.04
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Total 734 4490.12 $172453.68 $38.41
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Number of Children (Unduplicated) With at Least One Authorization 283