Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.00 $200.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 7 7 7.00 $350.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 13 13.00 $630.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 39 48.71 $2362.65 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 16.86 $817.57 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 17 25.14 $1219.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 54 55 59.21 $2871.54 $48.50
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Subtotal (Total Children Is Unduplicated) 115 148 177.92 $8868.09 $49.84
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 7.00 $10500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 11.07 $553.57 $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 20 21 13.06 $652.77 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 20 21 34.90 $872.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 9.33 $466.39 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 13.43 $335.84 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.17 $8.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 7.73 $193.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 7.06 $353.05 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 19 20 23.78 $594.58 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.20 $30.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 59 59 330.73 $16536.66 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 10.03 $501.67 $50.00
INTR -INTR INTERPRETER 2 3 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 88 89 481.11 $32657.52 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 5.71 $310.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 53 289.11 $19624.74 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 24.82 $1348.30 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 3.89 $3.89 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5264 EARMOLD 3 3 2.67 $49.92 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.29 $214.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 232 239 1308.29 $88807.06 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 14.43 $783.76 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 34.82 $459.64 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 251 309 2096.26 $1048.13 $0.50
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Subtotal (Total Children Is Unduplicated) 357 904 4750.90 $178636.31 $37.60
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Total 1052 4928.82 $187504.40 $38.04
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Number of Children (Unduplicated) With at Least One Authorization 375