Summary Report for FSPSAs Ending During the Report Period Center: 53
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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.00 $388.00 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.18 $9.67 $54.38
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 75 75 76.09 $9100.23 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 8 13.00 $1625.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.86 $92.86 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 3.53 $176.67 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 20 31.57 $1531.21 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 25 34.86 $1690.57 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 39 43 60.86 $2951.57 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 134 190 236.94 $17946.58 $75.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 10.00 $15000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 6.57 $452.51 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 28.26 $1413.10 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 27 27 41.31 $2065.72 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 5.50 $137.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 16.39 $819.52 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.73 $93.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 13.76 $688.09 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 13 40.45 $2022.39 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 11.53 $288.34 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 44 46 94.15 $2353.69 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 235 1325.60 $66280.00 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 3 3 6.04 $302.15 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 16.22 $810.95 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 5 6 105.14 $7137.10 $67.88
OCCT -97530HM OT SESSION BY OT ASST 27 27 342.03 $18579.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 29.14 $1978.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 40 40 404.81 $21989.38 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 27 18.55 $18.55 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 1.27 $82.45 $65.00
SENS -V5264 EARMOLD 5 5 6.98 $130.63 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 9.55 $477.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 24.57 $1667.91 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 41 43 459.56 $6066.22 $13.20
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Subtotal (Total Children Is Unduplicated) 311 541 3026.13 $152879.22 $50.52
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Total 731 3263.07 $170825.80 $52.35
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Number of Children (Unduplicated) With at Least One Authorization 381