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: 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) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.43 $26.23 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.10 $2.18 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 4.00 $217.52 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 16 18 23.14 $1388.57 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 8 8 13.50 $675.00 $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 56 77 134.00 $10050.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 3.00 $218.34 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 2.00 $300.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 13.00 $630.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 52 54 55.02 $2668.58 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 34 30.93 $1500.27 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 163 164 167.00 $8099.42 $48.50
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Subtotal (Total Children Is Unduplicated) 302 431 534.13 $31422.67 $58.83
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 13 14.20 $710.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 11 12.00 $600.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 29 31 33.90 $1695.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 10 10 12.93 $323.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 26.36 $1317.86 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.38 $84.59 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 18.71 $935.28 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.17 $54.17 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 30 31 47.84 $2391.90 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 12 11.59 $289.73 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 30.43 $380.36 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.29 $464.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 347 361 2089.88 $104494.21 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.00 $650.00 $50.00
INTR -INTR INTERPRETER 4 4 8.02 $400.84 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 86 90 614.31 $41699.21 $67.88
OCCT -97530HM OT SESSION BY OT ASST 19 22 150.57 $8179.05 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 88 579.01 $39303.16 $67.88
PHY -97110HM PT SESSION BY PT ASST 14 15 121.14 $6580.49 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 33 34 34.51 $34.51 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -V5264 EARMOLD 3 3 3.20 $59.90 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 284 293 2073.74 $140765.43 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 36 36 269.65 $3559.41 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 25 29 119.14 $59.57 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 52.00 $2600.00 $50.00
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Subtotal (Total Children Is Unduplicated) 697 1133 6352.97 $360782.26 $56.79
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Total 1565 6887.38 $392215.50 $56.95
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Number of Children (Unduplicated) With at Least One Authorization 733