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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 5 5 5.00 $234.00 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
OCTH -97003 OT EVAL BY LICENSED OT, 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) 7 13 13.00 $977.50 $75.19
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 21 21 31.78 $1588.85 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 24 19.00 $950.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.25 $6.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 6 19.85 $992.38 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 4 1.35 $33.75 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 30 47.25 $2362.39 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.33 $33.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 27 34.64 $1732.03 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 3.48 $87.08 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 19 19.25 $962.27 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 7 6.33 $158.13 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 66 70 954.36 $23858.93 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 7.43 $371.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 240 270 1509.58 $75478.82 $50.00
INTR -INTR INTERPRETER 38 41 78.47 $3923.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 108 119 446.20 $30288.06 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 19.21 $1043.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 174 185 749.36 $50866.29 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 12 44.64 $2425.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 27 27.37 $27.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 5.00 $2500.00 $500.00
SENS -V5264 EARMOLD 5 5 2.18 $40.77 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 483 534 2490.46 $169052.51 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 25 27 100.79 $1330.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 15.25 $762.50 $50.00
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Subtotal (Total Children Is Unduplicated) 858 1453 6636.78 $373875.54 $56.33
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Total 1466 6649.78 $374853.04 $56.37
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Number of Children (Unduplicated) With at Least One Authorization 859