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: 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.29 $10.57 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.29 $10.57 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.00 $8.83 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.43 $15.43 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.91 $19.85 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 5 5.00 $271.90 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 12 13 13.00 $780.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 11 12 19.50 $975.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.00 $555.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 46.00 $3450.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 15.00 $832.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 78 135.00 $10125.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 2.00 $300.00 $150.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 52 60.42 $2930.17 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 48 42.78 $2074.99 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 191 196 179.74 $8717.17 $48.50
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Subtotal (Total Children Is Unduplicated) 350 471 558.77 $32755.54 $58.62
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 13 14 22.86 $1142.78 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 12 11.18 $559.17 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.73 $18.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 27 29.93 $1496.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 11 15.72 $392.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 10.20 $510.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 3.33 $83.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 10.98 $549.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 7 12.40 $310.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 25 23.44 $1172.14 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 13 13 18.48 $462.09 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 26.00 $325.00 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 324 344 2134.32 $106716.19 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 35.90 $1794.77 $50.00
INTR -INTR INTERPRETER 4 4 17.12 $856.07 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 95 97 507.58 $34454.62 $67.88
OCCT -97530HM OT SESSION BY OT ASST 17 18 99.58 $5408.98 $54.32
PHY -97110 PT SESSION BY LICENSED PT 85 90 521.10 $35372.11 $67.88
PHY -97110HM PT SESSION BY PT ASST 9 9 63.07 $3426.03 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 38 39 48.27 $48.27 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 8 8 12.07 $225.89 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 285 309 1846.15 $125316.78 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 47 51 366.58 $4838.87 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 19 21 663.00 $331.50 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 15.86 $792.86 $50.00
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Subtotal (Total Children Is Unduplicated) 701 1150 6521.86 $332473.38 $50.98
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Total 1622 7080.92 $365239.49 $51.58
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Number of Children (Unduplicated) With at Least One Authorization 828