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: 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
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 10 10 10.00 $600.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $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 56 76 123.50 $9262.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 6.00 $436.68 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 10.00 $485.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 65 65 67.80 $3288.49 $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 40 40 43.74 $2121.26 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 171 173 159.55 $7738.39 $48.50
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Subtotal (Total Children Is Unduplicated) 333 476 563.85 $33347.93 $59.14
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 9.43 $471.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 9.34 $466.95 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 3.53 $88.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 22 21.27 $1063.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 8 12.23 $305.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 16 14.03 $701.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.32 $82.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 12.82 $640.84 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 4.37 $109.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 21 34.18 $1708.82 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 11.08 $277.08 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 4 4 62.86 $785.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 7.14 $178.57 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 290 305 1928.41 $96420.63 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 15.33 $766.43 $50.00
INTR -INTR INTERPRETER 1 1 3.60 $180.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 90 94 643.36 $43671.43 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 14 71.13 $3863.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 86 90 724.78 $49198.30 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 59.11 $3210.70 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 30 31 34.33 $34.33 $1.00
SENS -FM FM RECEIVER HEARING AID 3 3 3.00 $4950.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 3 3 3.76 $70.30 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 264 275 2154.32 $146235.57 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 12.43 $675.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 35 36 240.86 $3179.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6 6 48.14 $24.07 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.00 $50.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 54.14 $2707.15 $50.00
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Subtotal (Total Children Is Unduplicated) 637 1005 6215.45 $365890.39 $58.87
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Total 1481 6779.29 $399238.32 $58.89
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Number of Children (Unduplicated) With at Least One Authorization 685