Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 27 27 27.00 $1620.00 $60.00
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
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.00 $125.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 73 73 73.00 $3540.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 89 89 89.00 $4316.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 281 284 313.00 $15180.50 $48.50
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Subtotal (Total Children Is Unduplicated) 351 477 507.00 $25193.50 $49.69
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 8.90 $445.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 282 284 595.47 $29773.31 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 13 13 16.63 $415.70 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 6.04 $302.23 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 7.21 $360.48 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.14 $28.57 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 279 281 587.66 $29383.03 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 15 15 19.78 $494.59 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 48.00 $3524.16 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 28.29 $707.14 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 18.43 $460.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 320 322 2465.64 $123282.12 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 61 61 296.14 $20102.19 $67.88
OCCT -97530HM OT SESSION BY OT ASST 16 16 58.86 $3197.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 67 67 306.39 $20797.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 19 19 70.29 $3817.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 6.10 $6.10 $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 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 13.22 $661.19 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 296 304 1508.11 $102370.32 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 21 21 103.14 $1361.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 12.57 $1257.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 336 368 6622.37 $3311.18 $0.50
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Subtotal (Total Children Is Unduplicated) 514 1821 12804.39 $347097.09 $27.11
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Total 2298 13311.39 $372290.59 $27.97
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Number of Children (Unduplicated) With at Least One Authorization 531