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: 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 22 26 38.43 $1863.79 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.93 $56.00 $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 14 15 15.00 $750.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.14 $57.15 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 223 271 286.97 $13917.84 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 183 218 233.54 $11326.55 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 296 365 426.14 $20667.93 $48.50
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Subtotal (Total Children Is Unduplicated) 496 903 1010.15 $49308.25 $48.81
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 24.17 $1208.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 32 34 52.47 $2623.46 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 4 2.60 $65.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 5.77 $288.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 2 0.80 $20.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 4.40 $220.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 16 11.18 $558.77 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.16 $3.89 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 93 132 537.57 $13439.32 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 579 698 3588.61 $179430.64 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 333 425 1768.19 $120024.71 $67.88
PHY -97110 PT SESSION BY LICENSED PT 285 358 1475.65 $100166.87 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 20.44 $20.44 $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 4.64 $86.94 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 20 21.92 $1096.19 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 423 535 2127.83 $144436.91 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.00 $39.60 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.43 $942.86 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 480 599 2600.10 $1300.05 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 13 17 62.37 $3118.34 $50.00
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Subtotal (Total Children Is Unduplicated) 876 2894 12325.29 $571640.65 $46.38
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Total 3797 13335.44 $620948.90 $46.56
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Number of Children (Unduplicated) With at Least One Authorization 888