Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 1 1 1.00 $48.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 86 86 83.83 $5030.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 12.00 $561.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 3.36 $419.64 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 52 55 66.00 $3300.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 6.00 $450.00 $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 2 2 2.50 $187.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 3.00 $225.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 8 10.50 $582.75 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 14 14.00 $679.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 59 61 84.00 $4074.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.00 $727.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 116 120 121.00 $5868.50 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 293 400 438.19 $23530.69 $53.70
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 16 16 26.67 $1333.42 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 11.81 $590.55 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 63 66 89.50 $4474.76 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 1.93 $48.34 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 46 71.28 $3564.20 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.79 $19.72 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 33.08 $1654.22 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.06 $1.53 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 115 141.52 $7076.18 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 5.83 $145.70 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 36.86 $460.71 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.00 $200.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.43 $210.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 229 242 1493.10 $74654.86 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 18.54 $926.92 $50.00
INTR -INTR INTERPRETER 29 32 182.13 $9106.66 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 110 121 866.96 $58849.54 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 20.79 $1129.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 67 73 454.72 $30866.39 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 16.36 $888.52 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 14.09 $14.09 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.00 $260.00 $65.00
SENS -V5264 EARMOLD 12 12 10.64 $199.26 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 12 33.25 $1662.63 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 164 180 1159.90 $78734.13 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 21.57 $1171.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 42.25 $557.70 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 444 686 258074.31 $129037.15 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 10 64.50 $3224.76 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 513 1703 262916.87 $413063.47 $1.57
-----------------------------------------------------------------------------------------------------------------------------
Total 2103 263355.06 $436594.16 $1.66
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 552