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: 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 18.57 $687.14 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.21 $266.93 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 25.79 $954.07 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 13.00 $630.50 $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) 2 2 2.00 $108.76 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 23 23 24.00 $1440.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.01 $187.72 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 13.00 $1554.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 7.64 $382.15 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 96 101 198.54 $9926.79 $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 30 30 54.00 $2997.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 349 349 598.50 $44887.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 74 74 126.50 $9487.50 $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 304 304 527.71 $29288.14 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 264 264 438.21 $32866.07 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 13 15.00 $727.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 10 10.00 $485.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 3.00 $45.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 33 33 43.86 $2127.07 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 715 1389 2324.83 $155200.12 $66.76
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 31 35 40.00 $60000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 14 25.34 $1266.91 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 100 141.43 $7071.43 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 25 25 24.35 $608.81 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 19 27.61 $1380.71 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 13 15.53 $388.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.25 $12.50 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.68 $67.09 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 15.37 $768.58 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 3.88 $97.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 33 78.79 $3939.40 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 27 27 62.96 $1574.08 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 27 27 196.50 $4912.50 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.14 $307.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 14.14 $353.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 530 545 3543.65 $177182.52 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 3.86 $192.86 $50.00
INTR -INTR INTERPRETER 64 69 304.80 $15240.01 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 58 61 431.59 $29296.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.43 $186.24 $54.32
PHY -97110 PT SESSION BY LICENSED PT 145 157 984.11 $66801.05 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 21.00 $1140.72 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 55 56 60.77 $60.77 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 7.00 $455.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 3 3 3.00 $342.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 10 10 12.58 $235.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 31.00 $1550.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 354 378 2534.79 $172061.82 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 31 31 357.67 $4721.20 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 874 1146 6839.58 $3419.78 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 10.00 $500.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1022 2795 15815.80 $562719.49 $35.58
-----------------------------------------------------------------------------------------------------------------------------
Total 4188 18166.42 $718873.67 $39.57
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1206