Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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 3 3 3.46 $207.67 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 14 15.35 $718.38 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 12 12.00 $1435.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 18 32 33.81 $2509.75 $74.23
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 10.71 $16071.45 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 24 27 31.57 $1578.50 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 34 40.00 $2000.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 13 20.17 $1008.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 1.70 $42.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 43 61.12 $3056.11 $50.00
CONOP -CONOP CONSULT, OT, PHONE 8 9 7.64 $191.05 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 28.59 $1429.40 $50.00
CONPP -CONPP CONSULT, PT, PHONE 8 9 8.38 $209.59 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 35 42.19 $2109.45 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 15 10.79 $269.73 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 42 570.86 $14271.44 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 209 232 1522.89 $76144.71 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 4 2.97 $148.34 $50.00
INTR -INTR INTERPRETER 11 12 26.29 $1314.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 124 131 614.87 $41737.60 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.14 $442.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 189 896.91 $60881.97 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 18 18 18.00 $18.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 10 11 10.50 $5250.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5264 EARMOLD 12 13 5.50 $102.96 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 438 498 2832.93 $192299.42 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 12.11 $657.66 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 23.43 $309.26 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 4 3.53 $353.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 6 25.22 $1261.08 $50.00
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Subtotal (Total Children Is Unduplicated) 713 1392 6843.01 $423348.45 $61.87
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Total 1424 6876.82 $425858.21 $61.93
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Number of Children (Unduplicated) With at Least One Authorization 715