Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 5.59 $335.34 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 10.00 $500.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 4.00 $300.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 23 24.00 $1164.00 $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 13 13 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 30 30.00 $1455.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 75 99 114.59 $6596.24 $57.56
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 15.58 $779.21 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 101 113 170.56 $8527.98 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.50 $37.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 46 60.69 $3034.59 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 61 84.76 $4237.92 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 93 94 133.66 $6682.91 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 6.00 $150.00 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 57.00 $1425.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 200.00 $10000.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 151 155 942.34 $47117.12 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 3.67 $183.33 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.67 $83.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 79 82 568.59 $38595.94 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.14 $170.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 92 95 697.30 $47333.04 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 5 2.17 $40.56 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 9.43 $471.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.97 $148.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 168 1171.51 $79522.24 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.14 $133.89 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 1.97 $98.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.73 $136.67 $50.00
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Subtotal (Total Children Is Unduplicated) 281 859 4175.67 $252179.78 $60.39
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Total 959 4291.26 $258813.02 $60.31
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Number of Children (Unduplicated) With at Least One Authorization 315