Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 26.71 $1295.64 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.64 $38.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 35 36 36.00 $1800.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 201 228 229.20 $11116.20 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 133 152 157.71 $7649.15 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 237 265 275.57 $13365.21 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.50 $125.00 $50.00
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Subtotal (Total Children Is Unduplicated) 444 712 739.34 $36361.86 $49.18
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 12 14 29.60 $1480.24 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 115 126 206.89 $10344.25 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 57 77.23 $3861.65 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 44 63.60 $3180.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 78 82 119.11 $5955.46 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.50 $12.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 2 8.00 $587.36 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 57 61 391.00 $9775.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 514 560 3163.29 $158164.42 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 278 321 1346.00 $91366.51 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.21 $337.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 224 259 1096.08 $74401.62 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 17.78 $17.78 $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 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 3 3 5.53 $103.58 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 8 17.31 $865.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 325 376 1446.71 $98202.67 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.14 $94.29 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 7.21 $721.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 469 589 2434.08 $1217.04 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 20.33 $1016.67 $50.00
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Subtotal (Total Children Is Unduplicated) 781 2540 10466.61 $462770.72 $44.21
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Total 3253 11206.96 $499169.58 $44.54
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Number of Children (Unduplicated) With at Least One Authorization 798