Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 -AUDE UNSPECIFIED AUDE SERVICES 22 22 21.30 $1278.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 11.00 $1315.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 100 100 100.00 $4850.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 92 92 92.00 $4462.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 323 327 359.36 $17429.05 $48.50
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Subtotal (Total Children Is Unduplicated) 422 555 588.66 $29803.25 $50.63
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.93 $96.43 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 148 148 256.31 $12815.28 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 21 21 38.04 $951.07 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 15.76 $787.86 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.14 $3.47 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 3.89 $194.44 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.63 $15.83 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 300 303 357.05 $17852.61 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 25 34.55 $863.70 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 24.00 $1762.08 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 14 77.86 $1946.43 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 11.57 $289.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 378 382 2520.23 $126011.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 89 91 385.71 $26182.32 $67.88
OCCT -97530HM OT SESSION BY OT ASST 23 23 91.79 $4985.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 84 84 298.76 $20279.75 $67.88
PHY -97110HM PT SESSION BY PT ASST 18 18 82.79 $4496.94 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 3.66 $3.66 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 0.30 $5.62 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 15.60 $780.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 384 394 1792.93 $121704.21 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 76.86 $1014.51 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 387 418 2589.80 $1294.90 $0.50
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Subtotal (Total Children Is Unduplicated) 627 1974 8686.15 $351337.76 $40.45
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Total 2529 9274.81 $381141.01 $41.09
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Number of Children (Unduplicated) With at Least One Authorization 651