Summary Report for FSPSAs Ending During the Report Period Center: 54
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 58 61 57.25 $3434.81 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.00 $1076.40 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.00 $500.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 28 29 38.00 $1900.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 6 7.00 $525.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.30 $397.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 3.80 $285.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 8 10.50 $582.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 5.29 $396.43 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 16 17 17.00 $824.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 59 59.00 $2861.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 11 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 22 22.00 $1067.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 94 103 104.00 $5044.00 $48.50
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Subtotal (Total Children Is Unduplicated) 237 341 359.13 $19815.59 $55.18
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 15.43 $771.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 6.37 $318.33 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 64 67 135.95 $6797.73 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 2.63 $65.70 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 56 79.91 $3995.47 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 35.02 $1750.83 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 105 112 171.48 $8573.92 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 6.72 $167.92 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 231 246 1833.79 $91689.49 $50.00
INTR -INTR INTERPRETER 18 18 79.25 $3962.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 127 140 986.01 $66930.60 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 13.10 $711.59 $54.32
PHY -97110 PT SESSION BY LICENSED PT 85 91 546.48 $37094.78 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 29.00 $1575.29 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 19.72 $19.72 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 7 7 4.96 $92.77 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 34.18 $1709.05 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 200 217 1513.37 $102727.69 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 4.29 $56.57 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 406 631 272049.80 $136024.90 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 34.53 $1726.43 $50.00
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Subtotal (Total Children Is Unduplicated) 477 1683 277604.98 $467831.78 $1.69
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Total 2024 277964.12 $487647.36 $1.75
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Number of Children (Unduplicated) With at Least One Authorization 509