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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 32.57 $1205.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 39.79 $1472.07 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 9.00 $436.50 $48.50
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $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 26 26 25.08 $1504.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 7.00 $327.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 11.00 $1315.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 7.64 $382.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 96 101 198.04 $9901.79 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.00 $300.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 34 55.50 $4162.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 8.50 $637.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 17.50 $1312.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 31 31 51.50 $3862.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 31 54.30 $3013.65 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 350 350 599.50 $44962.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 73 73 125.00 $9375.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 59 59 99.86 $7489.29 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 305 305 529.21 $29371.39 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 265 265 439.21 $32941.07 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 8.29 $401.86 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 12.00 $582.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 16 16.00 $776.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 4.00 $60.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 28 28 43.14 $2092.43 $48.50
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Subtotal (Total Children Is Unduplicated) 733 1390 2331.27 $155363.20 $66.64
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 35 41.00 $61500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 14 15 25.14 $1257.15 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 100 154.06 $7703.10 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 38 40 21.21 $530.36 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 26 30.77 $1538.27 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 14 18.26 $456.49 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 5.36 $267.92 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.07 $126.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 8 8.44 $421.85 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 5.35 $133.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 39 41 54.80 $2739.82 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 34 36 38.65 $966.25 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 27 142.29 $3557.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 398 426 2538.35 $126917.48 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 3.86 $192.86 $50.00
INTR -INTR INTERPRETER 77 82 347.53 $17376.68 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 70 79 437.28 $29682.33 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 6.64 $360.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 152 174 937.86 $63661.73 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 29.14 $1583.04 $54.32
RSPT -RSPT RESPITE 1 1 16.00 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 58 60 62.73 $62.73 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 7.00 $3500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.00 $260.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 4 4 4.00 $456.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 9 10 11.60 $217.15 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 16.84 $842.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 437 488 2838.78 $192696.06 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 35 36 157.53 $2079.35 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 10.00 $1000.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 817 1151 6431.47 $3215.73 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 33.86 $1692.86 $50.00
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Subtotal (Total Children Is Unduplicated) 978 2900 14447.85 $527707.09 $36.52
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Total 4294 16818.91 $684542.36 $40.70
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Number of Children (Unduplicated) With at Least One Authorization 1461