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: 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 -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 9.00 $436.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 23.14 $1122.43 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 13.00 $630.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 50 53 59.71 $2896.14 $48.50
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Subtotal (Total Children Is Unduplicated) 84 102 113.86 $5665.77 $49.76
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 1.74 $87.22 $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 1.00 $50.00 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.53 $13.33 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 5.23 $261.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 6.00 $300.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 7.67 $383.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 12.90 $322.50 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 36 261.57 $13078.56 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 15.40 $770.24 $50.00
INTR -INTR INTERPRETER 1 1 7.29 $364.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 77 79 517.29 $35113.35 $67.88
PHY -97110 PT SESSION BY LICENSED PT 42 44 302.96 $20565.22 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 30.29 $1645.12 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.97 $3.97 $1.00
SENS -V5264 EARMOLD 3 3 9.37 $175.49 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 178 182 1246.11 $84585.76 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 16.71 $220.63 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 174 203 1897.14 $948.57 $0.50
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Subtotal (Total Children Is Unduplicated) 259 593 4349.18 $162089.23 $37.27
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Total 695 4463.04 $167755.01 $37.59
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Number of Children (Unduplicated) With at Least One Authorization 270