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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.25 $9.25 $37.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 12.57 $465.14 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 12.82 $474.39 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 11 14.00 $679.00 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 4 4.00 $217.52 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 29 29 29.00 $1740.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 10.00 $1196.00 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 3.25 $162.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 100 106 209.50 $10475.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 52 54 98.50 $7387.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 16.00 $1200.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 17.00 $1275.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 53 54 101.00 $7575.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 32 58.50 $3246.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 526 595 1117.71 $83828.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 84 90 172.00 $12900.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 124 133 244.50 $18337.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 486 552 1036.21 $57509.63 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 307 339 618.50 $46387.50 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 2.00 $145.56 $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 12 13 22.57 $1094.71 $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 4 4 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 26 26 38.32 $1858.47 $48.50
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Subtotal (Total Children Is Unduplicated) 907 2078 3827.56 $257882.18 $67.38
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 23 30.00 $45000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 23.57 $1178.57 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 98 110 157.11 $7855.36 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 13 13 11.09 $277.21 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 19 27.24 $1361.91 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 17 17 26.59 $664.65 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 12.47 $623.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 6 9.42 $235.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 14 24.43 $1221.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 10 16.78 $419.59 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 34 52.57 $2628.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 22 22 40.32 $1007.98 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 27 206.57 $5164.29 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.00 $450.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.71 $417.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 435 467 3004.43 $150221.70 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 21.14 $1057.15 $50.00
INTR -INTR INTERPRETER 80 106 399.39 $19969.31 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 54 62 350.00 $23758.01 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.57 $248.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 138 147 965.36 $65528.43 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 28.57 $1552.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 74 76 81.11 $81.11 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.00 $195.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 4 4 7.00 $1659.84 $237.12
SENS -V5264 EARMOLD 10 10 20.00 $374.40 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 316 365 2374.54 $161183.50 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 19 113.39 $1496.79 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 758 1036 6338.94 $3169.47 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.43 $621.43 $50.00
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Subtotal (Total Children Is Unduplicated) 896 2619 14391.74 $503022.60 $34.95
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Total 4701 18232.12 $761379.17 $41.76
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Number of Children (Unduplicated) With at Least One Authorization 1549