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: 07/01/10 and 09/30/10 Date of Report: 11-17-10 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 2 2 2.000000 $97.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 83 84 84.322222 $9697.0500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 13 17.000000 $2125.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 13 17.000000 $943.5000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 5.400000 $270.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 30 30 37.547619 $1821.0600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 41 44.714286 $2168.6400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 68 71 131.714286 $6388.1400 $48.5000
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Subtotal (Total Children Is Unduplicated) 180 261 342.698413 $23665.3900 $69.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.000000 $7500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 19.566667 $978.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 12 12 11.200001 $560.0100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 5.483335 $137.0900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 9.300001 $465.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.333334 $108.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 14 18.742857 $937.1500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.333334 $108.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 21.666668 $1083.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 10.017858 $250.4500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 4.333334 $318.1600 $73.4200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 40 41 68.747619 $1718.6900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 242 262 1431.271436 $71563.6100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 5.980952 $299.0500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 33.285714 $2259.4300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 36 36 261.309524 $14194.3400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 3 3 15.857143 $1076.3800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 40 42 334.219048 $18154.7700 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 21 14.766667 $14.7700 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.671233 $108.6300 $65.0000
SENS -V5264 EARMOLD 3 3 4.733333 $85.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 34.147619 $1707.3800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 57.714286 $3917.6500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 56 59 577.795235 $7626.8900 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 12.142857 $607.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 328 565 2972.620055 $136930.1200 $46.0600
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Total 826 3315.318468 $160595.5100 $48.4400
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Number of Children (Unduplicated) With at Least One Authorization 409