Summary Report for FSPSAs Initiated During the Report Period Center: 53
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 13 13 13.00 $630.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.31 $71.30 $54.38
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 88 89 93.74 $11211.66 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 11.29 $564.29 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 22.00 $1067.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 29 30.50 $1479.25 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 62 62 64.00 $3104.00 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 141 223 241.84 $18493.40 $76.47
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 13 14.00 $21000.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 6.07 $418.08 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 19.40 $970.24 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 18 25.74 $1286.91 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 6.32 $157.92 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 3.62 $181.19 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.17 $54.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 21.26 $1063.10 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 16.86 $843.10 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 14.75 $368.81 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 46 46 88.93 $2223.22 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 222 233 1210.64 $60532.18 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 8.43 $421.43 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 9 9 38.50 $1924.77 $50.00
OCCT -97530HM OT SESSION BY OT ASST 29 32 280.79 $15252.55 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 4.00 $271.52 $67.88
PHY -97110HM PT SESSION BY PT ASST 33 35 224.33 $12185.53 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 8.26 $8.26 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.59 $168.29 $65.00
SENS -V5264 EARMOLD 4 4 4.98 $93.18 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 15.67 $783.34 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 37 39 425.82 $5620.84 $13.20
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 303 504 2448.12 $128328.60 $52.42
-----------------------------------------------------------------------------------------------------------------------------
Total 727 2689.96 $146821.99 $54.58
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 324