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: 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 4 5 19.48 $720.89 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 9 11 7.43 $274.86 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 12 16 26.91 $995.74 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 11.00 $533.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 42 42 41.94 $2516.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 13 19.00 $2272.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 7 7 9.25 $462.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 96 116 194.75 $9737.50 $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 30 32 46.53 $2582.60 $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 445 449 660.36 $49526.79 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 49 49 76.71 $5753.57 $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 381 389 526.21 $39466.08 $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 7 7 12.29 $595.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.00 $291.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 16 23.14 $1122.43 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.14 $7.15 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 816 1571 2228.98 $151891.30 $68.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 21.00 $31500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 20 22 40.46 $2023.10 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 88 103 121.57 $6078.58 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 12 13 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 28 30 36.03 $1801.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 13 28.08 $701.90 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 7.53 $376.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.20 $130.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 23 18.59 $929.53 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 7 11.10 $277.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 35 41.83 $2091.66 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 15 16 30.63 $765.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 33 33 215.86 $5396.61 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 6.43 $321.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 387 408 2260.87 $113043.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 11.14 $557.15 $50.00
INTR -INTR INTERPRETER 60 63 278.33 $13916.53 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 72 80 557.21 $37823.69 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 9.29 $504.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 149 157 1074.45 $72933.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 49.50 $2688.83 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 36 36 36.73 $36.73 $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 4 4 6.00 $3000.00 $500.00
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 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 8.00 $1896.96 $237.12
SENS -V5264 EARMOLD 9 10 18.22 $341.12 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 25.24 $1261.90 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 473 506 3222.58 $218748.74 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 24 24 170.68 $2252.96 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 831 1320 6462.04 $3231.02 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 11.43 $571.43 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 997 2959 14795.05 $528807.48 $35.74
-----------------------------------------------------------------------------------------------------------------------------
Total 4546 17050.94 $681694.53 $39.98
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1209