Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 8 8 8.00 $388.00 $48.50
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 53 54 54.43 $2721.43 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 196 212 239.86 $11633.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 113 118 126.00 $6111.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 230 255 274.14 $13295.93 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 2.37 $118.34 $50.00
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Subtotal (Total Children Is Unduplicated) 435 652 709.80 $34728.77 $48.93
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 18 19 33.20 $1660.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 127 142 223.35 $11167.40 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 52 77.47 $3873.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 44.68 $2234.06 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 86 98 128.94 $6447.16 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.29 $681.76 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 51 64 318.50 $7962.50 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 507 568 3685.20 $184259.76 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 272 307 1380.23 $93690.04 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.14 $170.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 206 226 1033.55 $70157.23 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 32 36 24.38 $24.38 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 2 2 5.73 $107.33 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 12 27.91 $1395.72 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 2 2.57 $128.58 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 329 379 1605.38 $108973.36 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.14 $41.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 3.00 $300.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 402 503 2231.80 $1115.90 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 32.29 $1614.41 $50.00
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Subtotal (Total Children Is Unduplicated) 806 2449 10878.75 $498070.11 $45.78
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Total 3102 11589.55 $532835.88 $45.98
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Number of Children (Unduplicated) With at Least One Authorization 833