Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 5 5 7.00 $339.50 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 89 89 90.16 $10782.62 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 9 11.87 $1483.34 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.14 $63.43 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 5 5 5.00 $250.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 20.00 $970.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 28.00 $1358.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 57 58 64.14 $3110.93 $48.50
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Subtotal (Total Children Is Unduplicated) 175 218 230.31 $18504.62 $80.35
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 3.93 $5899.95 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 6 12.75 $637.62 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 16 19.93 $996.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 41.20 $1030.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 12.22 $610.95 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.63 $40.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 8.97 $448.34 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.18 $4.38 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 12 24.79 $1239.52 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 49.43 $1235.77 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 9.27 $680.35 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 52 52 111.01 $2775.24 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 220 241 1292.01 $64600.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 22.79 $1139.52 $50.00
INTR -INTR INTERPRETER 6 6 70.29 $3514.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 1 1.00 $67.88 $67.88
OCCT -97530HM OT SESSION BY OT ASST 31 36 261.90 $14226.15 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 12.86 $872.74 $67.88
PHY -97110HM PT SESSION BY PT ASST 39 41 364.76 $19813.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 12.51 $12.51 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 7 6.31 $410.12 $65.00
SENS -V5264 EARMOLD 6 8 10.46 $195.73 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 3.80 $190.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 18.14 $1231.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 48 50 571.13 $7538.89 $13.20
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Subtotal (Total Children Is Unduplicated) 314 546 2944.25 $129913.15 $44.12
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Total 764 3174.56 $148417.77 $46.75
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Number of Children (Unduplicated) With at Least One Authorization 410