Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.00 $291.00 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.27 $16.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 99 99 110.18 $13177.26 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 12 14 19.87 $2483.34 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 11 15.00 $832.50 $55.50
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.00 $50.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 5.00 $250.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 22.00 $1067.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 33 34 34.00 $1649.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 84 85 107.57 $5217.21 $48.50
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Subtotal (Total Children Is Unduplicated) 182 279 323.88 $25180.12 $77.74
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.93 $4399.95 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.00 $68.86 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 22.98 $1148.81 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 6.83 $341.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.73 $118.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 15.10 $755.24 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.73 $118.34 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 19.57 $978.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 9.71 $242.86 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 12.77 $937.33 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 39 82.46 $2061.55 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 6.86 $342.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 230 239 1262.59 $63129.69 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 31.14 $1557.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 3 3 32.14 $2181.86 $67.88
OCCT -97530HM OT SESSION BY OT ASST 33 39 245.44 $13332.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 36.14 $2453.38 $67.88
PHY -97110HM PT SESSION BY PT ASST 39 39 292.18 $15871.03 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 11.60 $11.60 $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 2 2 3.00 $195.00 $65.00
SENS -V5264 EARMOLD 3 3 7.02 $131.46 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 12.79 $639.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 36.00 $2443.68 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 54 54 509.08 $6719.87 $13.20
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Subtotal (Total Children Is Unduplicated) 311 500 2672.81 $121280.31 $45.38
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Total 780 2999.69 $146460.43 $48.83
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Number of Children (Unduplicated) With at Least One Authorization 344