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: 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 10.29 $380.57 $37.00
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Subtotal (Total Children Is Unduplicated) 4 4 10.54 $389.82 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 14 15.00 $727.50 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.00 $21.60 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 4.00 $217.52 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.00 $63.62 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 32 32 38.14 $2288.57 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 7.00 $327.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 16.33 $1953.46 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 6.25 $312.50 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 99 105 207.50 $10375.00 $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 527 596 1119.71 $83978.22 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 83 89 170.50 $12787.50 $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 1036.71 $57537.38 $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 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.86 $429.57 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 21.86 $1060.07 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 29 29 49.60 $2405.37 $48.50
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Subtotal (Total Children Is Unduplicated) 905 2100 3867.45 $260297.80 $67.30
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 27 34.00 $51000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 16 17 33.70 $1685.24 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 103 116 165.67 $8283.46 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 14 14 16.82 $420.48 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 26 37.23 $1861.75 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 26 27 36.48 $912.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 10 11.48 $573.89 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 11 15.10 $377.62 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 21.40 $1069.76 $50.00
CONPP -CONPP CONSULT, PT, PHONE 15 16 17.48 $437.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 28 33.20 $1660.08 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 27 30 32.06 $801.61 $25.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.86 $21.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 38 157.71 $3942.85 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 21.86 $546.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 547 569 3006.29 $150314.38 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 12.14 $607.14 $50.00
INTR -INTR INTERPRETER 77 106 271.60 $13579.77 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 51 55 340.79 $23132.54 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.21 $228.92 $54.32
PHY -97110 PT SESSION BY LICENSED PT 121 133 890.25 $60430.04 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 42.93 $2331.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 55 56 55.14 $55.14 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 6.00 $3000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.00 $195.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 5.00 $1185.60 $237.12
SENS -V5264 EARMOLD 14 14 29.00 $542.88 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.29 $64.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 271 304 2084.59 $141502.02 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 18 19 189.86 $2506.11 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 16.29 $1628.58 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 811 1118 5848.63 $2924.31 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 0.43 $21.43 $50.00
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Subtotal (Total Children Is Unduplicated) 949 2784 13443.49 $477957.76 $35.55
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Total 4888 17321.48 $738645.38 $42.64
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Number of Children (Unduplicated) With at Least One Authorization 1312