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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 9.00 $333.00 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 9.00 $333.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 9 9.00 $436.50 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 5.71 $61.71 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 6.71 $365.12 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 5.71 $181.77 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 26 26 26.00 $1560.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 11.00 $1315.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.00 $500.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 154 168 320.25 $16012.50 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 56 57 114.00 $8550.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 41 41 82.50 $6187.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 30 30 60.00 $3330.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 464 478 956.50 $71737.50 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 57 114.00 $8550.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 98 100 199.50 $14962.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 387 393 785.50 $43595.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 191 192 383.50 $28762.50 $75.00
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 12 13 19.29 $935.36 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 17 27.14 $1316.43 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.00 $30.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 23 41.43 $2009.28 $48.50
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Subtotal (Total Children Is Unduplicated) 872 1634 3194.75 $211683.93 $66.26
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 17 17.00 $25500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 13 14 38.08 $1903.89 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 128 139 191.09 $9554.41 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 30 18.06 $451.49 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 20 21 28.04 $1402.23 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 17 21 34.55 $863.75 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.53 $126.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.27 $56.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 16 20.27 $1013.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 7.80 $195.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 21 31.18 $1559.04 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 26 30 38.25 $956.16 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 39 271.71 $6792.87 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 4 4 26.43 $660.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 525 571 3165.26 $158262.87 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 5.00 $250.00 $50.00
INTR -INTR INTERPRETER 95 127 310.30 $15514.77 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 52 55 341.62 $23189.10 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.57 $194.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 129 137 935.17 $63479.60 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 44.29 $2405.60 $54.32
RSPT -RSPT RESPITE 1 1 38.40 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 57 57 58.47 $58.47 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $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 2 2 2.00 $228.00 $114.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 9 9 15.62 $292.45 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 20.29 $1014.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 309 339 2168.92 $147226.00 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 23 23 199.90 $2638.65 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 4.86 $485.71 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 839 1174 6394.70 $3197.35 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 12.43 $621.43 $50.00
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Subtotal (Total Children Is Unduplicated) 1007 2878 14456.03 $472526.58 $32.69
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Total 4515 17659.78 $684543.51 $38.76
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Number of Children (Unduplicated) With at Least One Authorization 1585