Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 2 2 11.89 $440.04 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 9 11 7.43 $274.86 $37.00
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Subtotal (Total Children Is Unduplicated) 10 13 19.32 $714.90 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 13 14.00 $679.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 3.00 $108.21 $36.07
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) 1 1 1.00 $54.38 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 31 32 32.00 $1920.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 20.00 $2392.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 9.25 $462.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 95 114 192.25 $9612.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 26 40.50 $3037.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 6.50 $487.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 11 15.00 $1125.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 31 44.50 $2469.75 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 448 452 664.36 $49826.79 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 50 50 78.21 $5866.07 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 83 83 105.14 $7885.72 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 293 294 416.50 $23115.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 383 391 528.71 $39653.58 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 3 3 5.00 $750.00 $150.00
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 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 24.43 $1184.79 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.14 $7.15 $50.00
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Subtotal (Total Children Is Unduplicated) 842 1573 2234.50 $152126.14 $68.08
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 18 18.00 $27000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 16 20 29.84 $1492.15 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 89 104 124.07 $6203.58 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 10 4.25 $106.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 18 22.23 $1111.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 14.80 $369.88 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.50 $12.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 22 18.29 $914.53 $50.00
CONPP -CONPP CONSULT, PT, PHONE 9 9 6.17 $154.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 19 21.60 $1080.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 27 28 33.72 $843.06 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 41 558.46 $13961.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 314 330 1726.31 $86315.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.86 $92.86 $50.00
INTR -INTR INTERPRETER 46 50 210.09 $10504.66 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 90 105 634.28 $43054.66 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 28.57 $1551.99 $54.32
PHY -97110 PT SESSION BY LICENSED PT 155 167 929.69 $63107.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 23.86 $1295.92 $54.32
RSPT -RSPT RESPITE 1 1 48.53 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 33 34 110.21 $110.21 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.00 $948.48 $237.12
SENS -V5264 EARMOLD 7 8 15.80 $295.78 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 1.04 $52.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 459 513 3233.60 $219496.89 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 25 26 189.11 $2496.22 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.29 $28.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 863 1237 5624.85 $2812.42 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 25.29 $1264.28 $50.00
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Subtotal (Total Children Is Unduplicated) 1062 2795 13670.31 $494727.46 $36.19
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Total 4381 15924.13 $647568.50 $40.67
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Number of Children (Unduplicated) With at Least One Authorization 1507