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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 6.74 $404.29 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 9.83 $460.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 19 26 31.57 $2092.68 $66.28
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 13 13.00 $19500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 20 20 28.39 $1419.35 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 47 49 59.00 $2950.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 7 7.00 $175.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 28 29 36.65 $1832.44 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 4 2.10 $52.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 61 66.68 $3334.23 $50.00
CONOP -CONOP CONSULT, OT, PHONE 10 10 8.91 $222.71 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 47 56.52 $2826.14 $50.00
CONPP -CONPP CONSULT, PT, PHONE 6 6 6.23 $155.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 58 61.49 $3074.47 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 4.56 $113.96 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 52 55 726.79 $18169.64 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 199 223 1274.28 $63714.07 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.10 $55.00 $50.00
INTR -INTR INTERPRETER 15 19 42.93 $2146.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 138 147 574.45 $38993.54 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 28.46 $1545.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 171 183 788.84 $53546.75 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 22.07 $1198.92 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 15.00 $15.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 5.00 $2500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 1.00 $237.12 $237.12
SENS -V5264 EARMOLD 8 8 4.68 $87.57 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 399 446 2389.12 $162173.44 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 2 7.43 $403.52 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 108.71 $1435.03 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 1.63 $163.33 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 3.43 $171.43 $50.00
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Subtotal (Total Children Is Unduplicated) 716 1450 6346.44 $382277.99 $60.24
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Total 1476 6378.01 $384370.68 $60.26
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Number of Children (Unduplicated) With at Least One Authorization 719