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: 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 -V5010 ASSESSMENT FOR HEARING AID 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.00 $194.00 $48.50
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Subtotal (Total Children Is Unduplicated) 20 25 25.00 $1490.10 $59.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 19 19 27.54 $1376.94 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 44 64.14 $3207.15 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 6 5.00 $125.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 8.07 $403.33 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 5.35 $133.75 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 30.75 $1537.63 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.28 $31.88 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 20 25.96 $1297.80 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.43 $60.63 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 19 21 27.02 $1351.25 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 3.69 $92.29 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 48 566.86 $14171.43 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 5.86 $292.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 253 278 1620.57 $81028.33 $50.00
INTR -INTR INTERPRETER 18 18 45.71 $2285.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 94 103 407.59 $27667.18 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 13 51.56 $2800.71 $54.32
PHY -97110 PT SESSION BY LICENSED PT 160 178 689.68 $46815.57 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 15 49.53 $2690.65 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 17.50 $17.50 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 4 4 2.76 $51.58 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 448 502 2202.20 $149485.48 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.93 $322.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 48 54 303.57 $4007.07 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 15.82 $791.08 $50.00
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Subtotal (Total Children Is Unduplicated) 790 1396 6196.36 $351644.82 $56.75
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Total 1421 6221.36 $353134.92 $56.76
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Number of Children (Unduplicated) With at Least One Authorization 793