Summary Report for FSPSAs Ending During the Report Period Center: 57
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
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 27 27 27.00 $1620.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 96 101 101.00 $4898.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 115 117 117.00 $5674.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 364 399 444.86 $21575.57 $48.50
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Subtotal (Total Children Is Unduplicated) 451 654 700.86 $34865.84 $49.75
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 10.13 $506.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 285 295 364.32 $18215.87 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 22 22 69.39 $1734.74 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 27.83 $1391.55 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.00 $25.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 9.87 $493.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.43 $135.72 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 347 372 442.28 $22114.16 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 22 22 63.57 $1589.16 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 12.00 $881.04 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 84.43 $2110.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 409 451 2807.26 $140363.24 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 94 103 467.96 $31765.42 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 57.07 $3100.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 98 101 460.32 $31246.61 $67.88
PHY -97110HM PT SESSION BY PT ASST 16 16 59.74 $3245.25 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 3.36 $3.36 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5264 EARMOLD 2 2 3.00 $56.16 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 26.20 $1310.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 404 450 1918.89 $130254.45 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 20 20 67.57 $891.94 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.71 $71.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 419 508 3965.18 $1982.59 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.00 $500.00 $50.00
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Subtotal (Total Children Is Unduplicated) 635 2437 10941.52 $396988.51 $36.28
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Total 3091 11642.38 $431854.35 $37.09
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Number of Children (Unduplicated) With at Least One Authorization 646