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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 2 2 0.70 $42.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 6.06 $283.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.00 $97.00 $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) 21 29 26.76 $1722.00 $64.36
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 18 18 24.14 $1207.22 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 46 67.14 $3357.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 6 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 17 25.48 $1273.82 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 5 5 1.30 $32.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 37 40 53.92 $2695.78 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 6 5.93 $148.34 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 21 27.65 $1382.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 5 5 2.18 $54.59 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 40 52.09 $2604.64 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 7.50 $187.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 65 901.29 $22532.13 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 232 1239.87 $61993.71 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 4.63 $231.67 $50.00
INTR -INTR INTERPRETER 19 19 46.29 $2314.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 105 116 491.26 $33346.48 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 16 65.80 $3574.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 170 186 801.61 $54413.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 14 42.17 $2290.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 16.37 $16.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 6.00 $3000.00 $500.00
SENS -V5264 EARMOLD 6 6 4.00 $74.88 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 419 467 2232.78 $151560.90 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.86 $46.56 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 38 41 178.85 $2360.86 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 31.74 $1586.91 $50.00
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Subtotal (Total Children Is Unduplicated) 749 1410 6339.84 $357011.80 $56.31
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Total 1439 6366.60 $358733.81 $56.35
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Number of Children (Unduplicated) With at Least One Authorization 753