Summary Report for FSPSAs Initiated During the Report Period Center: 53
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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 8.00 $388.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 81 81 82.11 $9820.49 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 9.00 $1125.00 $125.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 9 9 9.13 $456.67 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 30 36.41 $1765.87 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 31 31 38.14 $1849.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 44 47 57.14 $2771.43 $48.50
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Subtotal (Total Children Is Unduplicated) 157 215 243.94 $18386.48 $75.37
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 13.64 $682.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 18 20.13 $1006.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 8.88 $222.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 18.26 $913.09 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.73 $93.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 13.43 $671.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 16.93 $846.66 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 11.13 $278.21 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 4.13 $303.47 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 42 95.43 $2385.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 231 240 1166.15 $58307.41 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 26.55 $1327.38 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 2 66.00 $4480.08 $67.88
OCCT -97530HM OT SESSION BY OT ASST 34 36 300.23 $16308.42 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1 1 8.86 $601.22 $67.88
PHY -97110HM PT SESSION BY PT ASST 44 45 321.78 $17478.87 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 22 14.89 $14.89 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.43 $93.16 $65.00
SENS -V5264 EARMOLD 3 3 3.32 $62.19 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 12.23 $611.67 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 66.29 $4499.47 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 52 55 588.41 $7767.07 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.14 $57.15 $50.00
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Subtotal (Total Children Is Unduplicated) 331 536 2789.00 $125537.03 $45.01
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Total 751 3032.94 $143923.50 $47.45
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Number of Children (Unduplicated) With at Least One Authorization 348