Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.22 $73.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.00 $93.60 $46.80
EXIT -EXIT TRANSITION ASSESSMENT 10 13 13.00 $650.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 59 81 81.00 $3928.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 25 31.57 $1531.21 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 22 23 23.00 $1150.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 121 149 150.00 $7275.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 195 295 302.79 $14751.64 $48.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 8.00 $12000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.67 $233.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 92 110 165.80 $8289.89 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 76 110.17 $5508.35 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 42 66.98 $3349.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 121 173.03 $8651.56 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.07 $1.67 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 136 183 900.66 $45033.04 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 8.71 $435.72 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 104 114 753.74 $51163.76 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 6.54 $355.02 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 90 481.09 $32656.08 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 11.30 $613.56 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 6.06 $6.06 $1.00
SENS -V5264 EARMOLD 1 1 0.44 $8.32 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 7.43 $371.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 254 296 1364.04 $92590.95 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 50.07 $660.94 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 331 560 200220.44 $100110.22 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 11 36.63 $1831.43 $50.00
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Subtotal (Total Children Is Unduplicated) 411 1649 204382.85 $364220.49 $1.78
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Total 1944 204685.65 $378972.14 $1.85
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Number of Children (Unduplicated) With at Least One Authorization 453