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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 51 53 60.00 $2910.00 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.14 $6.76 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 10 10.00 $500.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 222 244 281.29 $13642.35 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 137 152 161.00 $7808.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 268 292 331.14 $16060.43 $48.50
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Subtotal (Total Children Is Unduplicated) 468 754 845.57 $41083.71 $48.59
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 4.14 $207.22 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 2.97 $148.61 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.84 $41.95 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 1.48 $74.17 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 58 62 244.57 $6114.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 568 641 3392.05 $169602.39 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.00 $50.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 322 364 1845.15 $125248.45 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.36 $453.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 239 270 1426.22 $96811.49 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 24 24 22.49 $22.49 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.00 $130.00 $65.00
SENS -V5264 EARMOLD 1 1 0.29 $5.41 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 13.98 $699.21 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 383 432 1988.65 $134989.31 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.00 $198.00 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 9.14 $914.29 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 532 680 3368.63 $1684.31 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 13 43.08 $2153.81 $50.00
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Subtotal (Total Children Is Unduplicated) 822 2525 12394.03 $540672.76 $43.62
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Total 3279 13239.60 $581756.47 $43.94
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Number of Children (Unduplicated) With at Least One Authorization 835