Summary Report for FSPSAs Ending During the Report Period Center: 57
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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 3 3 0.71 $0.00 $0.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 0.71 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 20 20 20.00 $1200.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 5.00 $625.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 109 109 109.00 $5286.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 89 93 93.00 $4510.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 320 333 349.00 $16926.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 399 566 582.00 $29204.10 $50.18
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 11.92 $596.11 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 351 361 567.73 $28386.29 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 16 17 20.37 $509.28 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.80 $90.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.00 $150.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 336 346 530.80 $26539.87 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 15 16 17.73 $443.33 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 130.00 $9544.60 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 8.71 $217.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 20.14 $503.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 372 383 2399.86 $119993.09 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.57 $128.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 92 94 400.72 $27201.12 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 14.57 $791.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 103 105 423.07 $28718.10 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 24.36 $1323.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 1.31 $1.31 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 43.07 $2153.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 340 357 1456.77 $98885.31 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 30.71 $405.43 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 408 488 3851.54 $1925.77 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 587 2222 9962.77 $349026.50 $35.03
-----------------------------------------------------------------------------------------------------------------------------
Total 2791 10545.48 $378230.60 $35.87
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 597