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: 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 1 1 2.00 $74.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.00 $74.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 8.00 $388.00 $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 14 14 14.00 $840.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.00 $1076.40 $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 463 477 954.50 $71587.50 $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 386 392 783.50 $43484.25 $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 17.57 $852.21 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.00 $582.00 $48.50
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.00 $15.00 $15.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 27 27 42.86 $2078.57 $48.50
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Subtotal (Total Children Is Unduplicated) 847 1614 3159.32 $209648.54 $66.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 20 20.00 $30000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 22.26 $1112.94 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 130 142 208.46 $10422.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 28 31 22.45 $561.13 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 29 30 49.67 $2483.65 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 21 23 27.52 $687.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 6 7.93 $396.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 23.61 $1180.72 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 8 14.89 $372.14 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 22 44.71 $2235.72 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 15 18 17.25 $431.37 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 35 38 211.71 $5292.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 11.57 $289.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 572 589 3603.40 $180169.83 $50.00
INTR -INTR INTERPRETER 105 138 321.93 $16096.44 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 51 54 396.70 $26928.00 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.00 $434.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 133 139 947.96 $64347.50 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 11.86 $644.08 $54.32
RSPT -RSPT RESPITE 1 1 10.13 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 58 59 69.16 $69.16 $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 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.00 $114.00 $114.00
SENS -V5264 EARMOLD 6 6 11.00 $205.92 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 16.71 $835.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 245 271 1830.10 $124227.19 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 94.00 $1240.80 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 9.14 $914.28 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 888 1159 6399.90 $3199.94 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.29 $714.29 $50.00
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Subtotal (Total Children Is Unduplicated) 1027 2813 14431.31 $478323.95 $33.14
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Total 4428 17592.63 $688046.49 $39.11
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Number of Children (Unduplicated) With at Least One Authorization 1325