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: 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 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $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) 2 2 2.00 $108.76 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 8.00 $956.80 $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 10 12 18.00 $900.00 $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 66 99 169.00 $12675.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 4.00 $291.12 $72.78
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 47 47 40.92 $1984.46 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 16 18.40 $892.24 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 44 44 36.22 $1756.78 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 154 156 141.51 $6863.18 $48.50
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Subtotal (Total Children Is Unduplicated) 309 474 577.62 $35618.34 $61.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 15.43 $771.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 6.75 $337.50 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 34 39 37.13 $1856.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 6.80 $170.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 21 16.33 $816.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.43 $85.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 17.67 $883.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 6.40 $160.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 41 37.39 $1869.29 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 5.80 $145.00 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 16.43 $205.36 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.43 $471.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 318 336 1986.94 $99347.14 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 4.86 $243.10 $50.00
INTR -INTR INTERPRETER 4 4 15.40 $770.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 86 89 565.02 $38353.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 15 110.76 $6016.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 91 93 724.79 $49198.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 15 15 98.14 $5331.13 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 33 33 36.83 $36.83 $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 3 3 5.00 $2500.00 $500.00
SENS -V5264 EARMOLD 7 8 11.10 $207.79 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 225 242 1671.85 $113484.99 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 20.29 $1101.92 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 43 46 277.08 $3657.41 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 9 10 746.29 $373.14 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 6.43 $321.43 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 10.86 $542.86 $50.00
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Subtotal (Total Children Is Unduplicated) 665 1070 6473.63 $333909.33 $51.58
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Total 1545 7052.24 $369564.67 $52.40
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Number of Children (Unduplicated) With at Least One Authorization 701