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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 6 6 6.00 $280.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.00 $48.50 $48.50
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Subtotal (Total Children Is Unduplicated) 11 17 17.00 $1242.40 $73.08
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 24 25 44.10 $2205.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 25 25 22.75 $1137.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 4 4 1.50 $37.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 4 4 7.03 $351.67 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 1.79 $44.76 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 22 42.12 $2106.13 $50.00
CONOP -CONOP CONSULT, OT, PHONE 2 3 1.52 $37.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 19.10 $954.89 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.42 $10.42 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 8.76 $437.85 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 6 6 4.36 $108.93 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 56 739.64 $18491.07 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 230 249 1436.88 $71843.76 $50.00
INTR -INTR INTERPRETER 40 50 133.29 $6664.29 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 112 127 456.81 $31008.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 6 16.96 $921.50 $54.32
PHY -97110 PT SESSION BY LICENSED PT 200 225 913.52 $62009.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 10.93 $593.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 40 42 42.00 $42.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 6.00 $3000.00 $500.00
SENS -V5264 EARMOLD 6 6 2.74 $51.38 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 493 562 2590.59 $175849.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 44 49 318.50 $4204.20 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 13 14 396.57 $198.29 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 10.93 $546.43 $50.00
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Subtotal (Total Children Is Unduplicated) 859 1520 7236.81 $392056.77 $54.18
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Total 1537 7253.81 $393299.17 $54.22
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Number of Children (Unduplicated) With at Least One Authorization 859