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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 11.86 $438.71 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 11.86 $438.71 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.00 $32.60 $16.30
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.00 $598.00 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.29 $535.71 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 0.29 $14.29 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 5 6 8.00 $400.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.00 $300.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 4 5.00 $277.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 33 33 57.50 $4312.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 3.50 $262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 25 43.00 $2386.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 67 100 171.00 $12825.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 2.00 $145.56 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 12.00 $582.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 56 56 51.14 $2480.46 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 15 15 13.36 $647.74 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 48 48 48.73 $2363.25 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 158 162 142.78 $6924.71 $48.50
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Subtotal (Total Children Is Unduplicated) 343 486 584.57 $35729.51 $61.12
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 7.23 $361.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 8 9.08 $454.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.73 $18.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 18.30 $915.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 8.60 $215.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 10.37 $518.33 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.13 $78.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 11.78 $589.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 8.49 $212.20 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 24 24.88 $1244.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 13.59 $339.70 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 68.29 $853.57 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 319 335 2024.23 $101211.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 24.50 $1225.25 $50.00
INTR -INTR INTERPRETER 2 2 10.31 $515.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 90 98 573.67 $38940.53 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 14 79.14 $4298.79 $54.32
PHY -97110 PT SESSION BY LICENSED PT 105 110 657.97 $44663.13 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 16 123.29 $6696.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 36 36 34.79 $34.79 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5264 EARMOLD 4 4 2.59 $48.46 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 254 271 1790.59 $121544.96 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 53.14 $2886.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 48 52 345.79 $4564.37 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 7 7 1905.86 $952.93 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 2 7.43 $371.43 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 57.06 $2852.86 $50.00
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Subtotal (Total Children Is Unduplicated) 663 1074 7881.83 $344258.10 $43.68
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Total 1562 8478.27 $380426.32 $44.87
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Number of Children (Unduplicated) With at Least One Authorization 807