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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 21 21.71 $1053.14 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.11 $66.67 $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
EVAL -EVAL DEVELOPMENTAL EVALUATION 34 35 61.86 $3092.86 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 233 261 267.46 $12971.90 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 159 178 202.71 $9831.64 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 275 313 340.71 $16524.64 $48.50
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Subtotal (Total Children Is Unduplicated) 488 816 904.57 $44262.86 $48.93
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 17.97 $898.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 92 96 121.94 $6096.78 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 0.83 $20.84 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 38 43.41 $2170.55 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.17 $4.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 32 47.33 $2366.66 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 62 74.71 $3735.28 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.03 $75.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 88 103 565.79 $14144.65 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 539 632 3596.62 $179830.82 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 313 386 1893.76 $128548.38 $67.88
PHY -97110 PT SESSION BY LICENSED PT 242 303 1367.47 $92823.69 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.86 $318.16 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 21 23 21.56 $21.56 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 2 2 2.42 $45.34 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 16 33.56 $1678.09 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 374 455 2011.11 $136514.40 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.07 $14.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 451 561 2756.74 $1378.37 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 15 76.29 $3814.53 $50.00
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Subtotal (Total Children Is Unduplicated) 849 2739 12643.63 $575500.57 $45.52
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Total 3555 13548.20 $619763.43 $45.75
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Number of Children (Unduplicated) With at Least One Authorization 874