Summary Report for FSPSAs Ending During the Report Period Center: 55
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 -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 5 5 5.00 $250.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 5.00 $242.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 33 41.05 $1990.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 10 15.86 $769.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 48 50 57.86 $2806.07 $48.50
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Subtotal (Total Children Is Unduplicated) 98 121 146.76 $7706.67 $52.51
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 9.00 $450.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 3.00 $150.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 6.47 $161.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 22.71 $1135.48 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.47 $61.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 3.59 $179.45 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 14.75 $368.75 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 42 43 257.11 $12855.71 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 173.71 $8685.72 $50.00
INTR -INTR INTERPRETER 3 4 3.86 $192.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 82 82 484.72 $32902.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 5.79 $314.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 44 45 219.12 $14873.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 27.93 $1517.08 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 6.96 $6.96 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 2.00 $3300.00 $1650.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 9.80 $2323.78 $237.12
SENS -V5264 EARMOLD 3 3 6.02 $112.73 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 214 221 1278.39 $86777.25 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 9.86 $130.12 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 210 256 1972.73 $986.37 $0.50
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Subtotal (Total Children Is Unduplicated) 315 719 4522.99 $169086.74 $37.38
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Total 840 4669.75 $176793.40 $37.86
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Number of Children (Unduplicated) With at Least One Authorization 335