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: 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.84 $31.24 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 0.84 $31.24 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 18 17.89 $1073.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 14.89 $1780.71 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 103 104 107.30 $5204.05 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 125 126 126.00 $6111.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 360 369 376.04 $18237.85 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 11.00 $1100.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 448 636 656.12 $33803.75 $51.52
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 38 38 53.25 $2662.58 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 30 30 9.31 $232.65 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 17.51 $875.36 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.02 $25.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 14.86 $742.94 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.39 $9.86 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 304 307 213.32 $10665.97 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 37 37 10.22 $255.43 $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 67.29 $1682.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 384 394 2613.00 $130650.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 105 108 440.50 $29901.18 $67.88
OCCT -97530HM OT SESSION BY OT ASST 13 13 50.43 $2739.29 $54.32
PHY -97110 PT SESSION BY LICENSED PT 119 120 567.61 $38529.23 $67.88
PHY -97110HM PT SESSION BY PT ASST 7 7 23.23 $1262.03 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 4.59 $4.59 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 1 1 0.89 $16.64 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 8.43 $421.35 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 396 409 1926.61 $130778.27 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 47.00 $620.40 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 422 482 3232.84 $1616.41 $0.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 649 2005 9318.28 $356410.05 $38.25
-----------------------------------------------------------------------------------------------------------------------------
Total 2642 9975.24 $390245.04 $39.12
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 660