Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 6.00 $717.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 2 2 2.00 $100.00 $50.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 20 18.51 $897.52 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 30.86 $1496.57 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 49.71 $2411.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 46 47.00 $2279.50 $48.50
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Subtotal (Total Children Is Unduplicated) 89 116 168.08 $8646.63 $51.44
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 4.77 $238.34 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 12 12.00 $600.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.00 $50.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 0.57 $28.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.05 $1.25 $25.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.05 $1.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 4.32 $215.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 2.20 $110.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 51 53 287.99 $14399.40 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 271.86 $13592.86 $50.00
INTR -INTR INTERPRETER 2 2 10.43 $521.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 98 101 585.35 $39733.71 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.43 $349.20 $54.32
PHY -97110 PT SESSION BY LICENSED PT 49 49 299.03 $20298.37 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 27.00 $1466.63 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 4 4 4.00 $4.00 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 3 4 3.73 $69.89 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 211 217 1388.82 $94273.16 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 16 16 131.29 $1732.97 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 218 264 2059.99 $1030.00 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 20.57 $1028.57 $50.00
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Subtotal (Total Children Is Unduplicated) 316 757 5125.44 $191719.43 $37.41
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Total 873 5293.52 $200366.06 $37.85
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Number of Children (Unduplicated) With at Least One Authorization 329