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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 7.14 $264.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 7.14 $264.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -AUDE UNSPECIFIED AUDE SERVICES 19 19 19.00 $1140.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 31.29 $1464.17 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 8.00 $956.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 8 8 11.75 $587.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.50 $112.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 38 38 60.00 $4500.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 28 45.00 $2497.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 54 74 120.50 $9037.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 5 5 7.00 $509.46 $72.78
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 68 68 74.76 $3625.80 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 57 58 48.60 $2357.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 179 184 171.40 $8313.08 $48.50
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Subtotal (Total Children Is Unduplicated) 379 509 617.80 $36173.06 $58.55
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.10 $555.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 8.59 $429.59 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 2.45 $61.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 20 18.57 $928.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 6.58 $164.58 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 19 15.68 $784.05 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 14.13 $706.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.50 $12.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 27 27.35 $1367.32 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.48 $87.08 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 69.00 $862.50 $12.50
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 310 335 2035.74 $101786.75 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 11.43 $571.43 $50.00
INTR -INTR INTERPRETER 2 2 5.27 $263.33 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 112 120 685.38 $46523.57 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 14 102.00 $5540.38 $54.32
PHY -97110 PT SESSION BY LICENSED PT 109 114 625.87 $42484.34 $67.88
PHY -97110HM PT SESSION BY PT ASST 20 20 124.94 $6786.50 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 45 45 51.10 $51.10 $1.00
SENS -FM FM RECEIVER HEARING AID 7 7 7.00 $11550.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 7 7 7.68 $143.73 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 288 309 1863.37 $126485.62 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.43 $838.09 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 35 35 222.07 $2931.34 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 1.67 $0.83 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 3.25 $162.38 $50.00
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Subtotal (Total Children Is Unduplicated) 694 1147 5961.05 $362338.56 $60.78
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Total 1657 6585.99 $398775.90 $60.55
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Number of Children (Unduplicated) With at Least One Authorization 842