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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 18 19 22.71 $1101.64 $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
EVAL -EVAL DEVELOPMENTAL EVALUATION 19 19 19.00 $950.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 208 231 243.06 $11788.27 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 144 149 147.63 $7159.99 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 262 289 319.14 $15478.43 $48.50
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Subtotal (Total Children Is Unduplicated) 451 710 755.54 $36814.33 $48.73
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 7.17 $358.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 45 49 39.67 $1983.66 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 3.37 $84.17 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 16 8.03 $401.39 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 5.03 $251.67 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 37 31.19 $1559.29 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.79 $19.72 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 62 67 417.21 $10430.35 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 487 545 3107.32 $155365.95 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 293 339 1516.68 $102952.23 $67.88
PHY -97110 PT SESSION BY LICENSED PT 233 253 1166.82 $79203.92 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 25 21.51 $21.51 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -V5264 EARMOLD 1 1 0.84 $15.81 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 15.54 $776.90 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 365 423 1876.70 $127390.66 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 456 562 2700.84 $1350.42 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 12 45.79 $2289.29 $50.00
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Subtotal (Total Children Is Unduplicated) 757 2360 10967.50 $485505.27 $44.27
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Total 3070 11723.05 $522319.60 $44.55
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Number of Children (Unduplicated) With at Least One Authorization 776