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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 8 8 9.20 $430.56 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.00 $97.00 $48.50
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Subtotal (Total Children Is Unduplicated) 10 17 18.20 $1364.76 $74.99
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.00 $4500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 28 32 42.54 $2126.87 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 18 19.25 $962.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 2.50 $62.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 3.23 $161.67 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 27 32.52 $1625.89 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.80 $70.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 20.47 $1023.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.72 $42.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 13 20.77 $1038.46 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 4 4 2.58 $64.38 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 54 63 893.29 $22332.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 235 1387.16 $69358.15 $50.00
INTR -INTR INTERPRETER 40 44 134.43 $6721.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 97 123 380.68 $25840.34 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 18.43 $1001.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 194 235 865.66 $58760.91 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 18.86 $1024.32 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 36 40 40.00 $40.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 7.00 $3500.00 $500.00
SENS -V5264 EARMOLD 7 7 2.33 $43.68 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 499 598 2453.08 $166515.04 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 35 37 256.43 $3384.85 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 8 9 183.43 $91.71 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 7.29 $364.29 $50.00
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Subtotal (Total Children Is Unduplicated) 807 1533 6800.42 $370756.41 $54.52
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Total 1550 6818.62 $372121.17 $54.57
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Number of Children (Unduplicated) With at Least One Authorization 808