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: 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
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
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 8 14 14.00 $1026.00 $73.29
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 22 22 38.34 $1917.07 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 27 21.00 $1050.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.25 $6.25 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 5.57 $278.33 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 6 6 8.79 $219.65 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 18 30.16 $1508.10 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 3.28 $82.08 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 11 13.81 $690.36 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.62 $40.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 12 14.86 $743.21 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 9.47 $236.73 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 30 527.21 $13180.37 $25.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 2.29 $114.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 231 1458.21 $72910.28 $50.00
INTR -INTR INTERPRETER 38 41 87.60 $4380.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 103 114 422.67 $28690.62 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 5 19.36 $1051.48 $54.32
PHY -97110 PT SESSION BY LICENSED PT 177 199 905.74 $61481.67 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 8 15.14 $822.57 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 17 17.43 $17.43 $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 4.52 $84.66 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 442 484 2435.15 $165297.78 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 79.64 $1051.28 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 6 6 200.71 $100.36 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 29.18 $1458.93 $50.00
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Subtotal (Total Children Is Unduplicated) 734 1278 6360.00 $364413.89 $57.30
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Total 1292 6374.00 $365439.89 $57.33
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Number of Children (Unduplicated) With at Least One Authorization 735