Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 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
--------------------------------------------------------------------
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 5.66 $339.32 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 6.14 $307.15 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.00 $225.00 $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 1 1 1.00 $55.50 $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 16 17 17.00 $824.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 14.00 $679.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 37 37 37.00 $1794.50 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 72 99 112.80 $6764.37 $59.97
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 9.57 $659.09 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 10.00 $688.60 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 17.57 $878.58 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 84 88 143.98 $7198.99 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 51 75.63 $3781.25 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 45 64.10 $3205.01 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.22 $5.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 95 101 157.11 $7855.65 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 10.50 $262.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 70.00 $1750.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 140.29 $7014.28 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.03 $51.67 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 7.57 $189.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 123 126 863.00 $43150.22 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 2 2 5.10 $255.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 80 85 605.93 $41130.75 $67.88
PHY -97110 PT SESSION BY LICENSED PT 81 84 618.92 $42012.55 $67.88
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 3.00 $711.36 $237.12
SENS -V5264 EARMOLD 5 5 5.89 $110.24 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 3 3 9.10 $455.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 165 173 1196.92 $81247.19 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.64 $8.49 $13.20
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 3.27 $163.34 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.57 $178.57 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 274 797 4028.43 $246000.65 $61.07
-----------------------------------------------------------------------------------------------------------------------------
Total 897 4142.23 $252802.02 $61.03
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 284