Summary Report for FSPSAs Ending During the Report Period Center: 55
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 2 2 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 14 13.51 $655.29 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 33 33 34.00 $1649.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 11.00 $533.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 37.86 $1836.07 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 48 68.67 $3330.56 $48.50
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Subtotal (Total Children Is Unduplicated) 94 124 173.04 $8673.22 $50.12
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 19.50 $975.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 4.00 $200.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.40 $20.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.07 $103.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 4.60 $230.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 7.14 $357.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 39 41 218.70 $10934.77 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 29.54 $1477.15 $50.00
INTR -INTR INTERPRETER 1 1 5.86 $292.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 98 109 622.54 $42257.74 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 0.29 $15.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 56 59 299.14 $20305.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 6 16.30 $885.55 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 10.93 $10.93 $1.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.00 $474.24 $237.12
SENS -V5264 EARMOLD 4 5 14.31 $267.90 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 216 230 1210.72 $82183.35 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 43.64 $576.08 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 213 263 1901.72 $950.86 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 12.00 $600.01 $50.00
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Subtotal (Total Children Is Unduplicated) 315 760 4429.40 $169118.29 $38.18
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Total 884 4602.44 $177791.51 $38.63
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Number of Children (Unduplicated) With at Least One Authorization 339