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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 17 18.98 $1138.58 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 12.43 $1553.58 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 14 23.00 $1725.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 6.50 $487.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 14.00 $777.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 75 108 166.00 $12450.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $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 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 66 67 62.72 $3042.03 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 42 42 36.53 $1771.60 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 167 171 165.73 $8037.86 $48.50
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Subtotal (Total Children Is Unduplicated) 346 460 533.88 $32716.98 $61.28
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 15 19.44 $972.15 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 10 7.96 $397.78 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.50 $37.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 12 20.95 $1047.39 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 1.55 $38.75 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 24.25 $1212.38 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 2.93 $73.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 19.53 $976.55 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 2.53 $63.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 21 22.12 $1105.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 5.37 $134.29 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 29.43 $367.86 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 2.57 $128.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.71 $117.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 264 285 1742.34 $87116.77 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 66.79 $3339.53 $50.00
INTR -INTR INTERPRETER 1 1 2.33 $116.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 116 129 896.09 $60826.32 $67.88
OCCT -97530HM OT SESSION BY OT ASST 20 22 101.74 $5526.25 $54.32
PHY -97110 PT SESSION BY LICENSED PT 107 119 784.86 $53276.27 $67.88
PHY -97110HM PT SESSION BY PT ASST 19 19 89.86 $4881.05 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 39 40 48.92 $48.92 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 8 8 8.19 $153.30 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 302 317 2119.33 $143859.91 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.43 $23.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 45 49 320.93 $4236.26 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 27.79 $1389.29 $50.00
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Subtotal (Total Children Is Unduplicated) 680 1117 6382.42 $379617.37 $59.48
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Total 1577 6916.31 $412334.36 $59.62
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Number of Children (Unduplicated) With at Least One Authorization 826