Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
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 11 12 12.00 $720.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 12.71 $1589.29 $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 72 104 160.00 $12000.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.00 $300.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 15 15 15.00 $727.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 61 62 53.41 $2590.45 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 54 54 46.46 $2253.37 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 164 166 160.87 $7802.42 $48.50
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Subtotal (Total Children Is Unduplicated) 324 461 524.96 $32026.17 $61.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 10.90 $545.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 12.10 $605.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 3.89 $97.29 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 15 17.01 $850.56 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.18 $4.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 32.40 $1620.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.92 $22.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 14.18 $709.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.77 $119.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 26 41.23 $2061.31 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.63 $90.83 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 62.57 $782.14 $12.50
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.43 $21.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 278 286 1845.91 $92295.52 $50.00
INTR -INTR INTERPRETER 1 2 5.93 $296.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 119 130 853.66 $57946.56 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 58.14 $3158.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 104 110 780.59 $52986.14 $67.88
PHY -97110HM PT SESSION BY PT ASST 22 22 116.06 $6304.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 44 44 53.41 $53.41 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 6 6 6.69 $125.22 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 268 275 1908.14 $129524.55 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 27.29 $1482.16 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 29 30 193.07 $2548.54 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 1.10 $0.55 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.32 $615.95 $50.00
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Subtotal (Total Children Is Unduplicated) 693 1040 6074.52 $363191.80 $59.79
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Total 1501 6599.48 $395217.97 $59.89
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Number of Children (Unduplicated) With at Least One Authorization 721