Summary Report for FSPSAs Ending During the Report Period Center: 54
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 11.14 $412.29 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 11.14 $412.29 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.00 $97.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 66 66 66.30 $3978.19 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 16 16.00 $1913.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 5 10.00 $1250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 9.29 $1160.71 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 22 25 30.00 $1500.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.00 $450.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.50 $112.50 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 4.00 $300.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 6 6.00 $450.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 10.50 $582.75 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 13 20.14 $976.93 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 49 54 54.00 $2619.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 16 18.43 $893.79 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.00 $727.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 122 128 130.43 $6325.79 $48.50
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Subtotal (Total Children Is Unduplicated) 254 372 405.59 $23607.83 $58.21
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 11.00 $757.46 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 20.49 $1024.29 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 7.92 $395.95 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.60 $65.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 115 122 172.55 $8627.69 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 9 8.51 $212.64 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 67 91.34 $4567.15 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 4 0.77 $19.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 27.05 $1352.47 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 3.71 $92.78 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 132 166.14 $8307.25 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 4 5.44 $136.11 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 240 263 1660.54 $83027.05 $50.00
INTR -INTR INTERPRETER 14 15 55.88 $2793.81 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 151 160 1007.56 $68393.09 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 19.57 $1063.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 88 96 558.64 $37920.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 22.05 $1197.50 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 19 19.00 $19.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 6 6 7.72 $144.56 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 35.39 $1769.53 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 234 261 1662.18 $112829.01 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 64.43 $850.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 432 684 251082.45 $125541.23 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 47.86 $2392.86 $50.00
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Subtotal (Total Children Is Unduplicated) 533 1924 256761.79 $463736.53 $1.81
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Total 2297 257178.52 $487756.65 $1.90
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Number of Children (Unduplicated) With at Least One Authorization 566