Summary Report for FSPSAs Ending During the Report Period Center: 06
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 10 10 7.17 $265.40 $37.00
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Subtotal (Total Children Is Unduplicated) 10 10 7.17 $265.40 $37.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 7.59 $455.14 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.93 $230.88 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.59 $668.61 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 11 12 15.00 $750.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 6.00 $291.00 $48.50
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Subtotal (Total Children Is Unduplicated) 35 40 49.11 $2880.63 $58.66
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 12.00 $18000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 15 15 31.10 $1554.76 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 55 75.00 $3750.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 3 3.00 $75.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 33 35 34.04 $1702.08 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 4.40 $110.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 37 28.37 $1418.63 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.20 $30.09 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 16.35 $817.49 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 2.12 $52.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 33 27.77 $1388.33 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 3.15 $78.75 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 25 334.00 $8350.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 278 320 2187.22 $109361.20 $50.00
INTR -INTR INTERPRETER 14 14 65.21 $3260.71 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 260 302 1198.57 $81359.03 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 13 53.82 $2923.71 $54.32
PHY -97110 PT SESSION BY LICENSED PT 264 305 1380.26 $93692.33 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 1.45 $78.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 3.49 $3.49 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 2 2 2.00 $37.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 527 615 3232.04 $219390.91 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 14.29 $776.00 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 15.71 $207.43 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 8 10 12.00 $1200.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 13 75.43 $3771.44 $50.00
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Subtotal (Total Children Is Unduplicated) 775 1856 8816.00 $554127.60 $62.85
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Total 1906 8872.28 $557273.63 $62.81
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Number of Children (Unduplicated) With at Least One Authorization 792