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: 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 4 4 4.00 $187.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.00 $478.40 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 2 2 3.00 $150.00 $50.00
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 6.14 $614.29 $100.00
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Subtotal (Total Children Is Unduplicated) 7 11 17.14 $1429.89 $83.41
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 10.00 $15000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 29 31 42.77 $2138.66 $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 2 2 2.07 $103.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 2.27 $56.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 13 18.17 $908.57 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.94 $98.57 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 13.46 $673.21 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.27 $6.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 8 8.88 $444.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 3 0.90 $22.50 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 37 47 383.29 $9582.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 247 1460.39 $73019.31 $50.00
INTR -INTR INTERPRETER 38 47 94.14 $4707.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 99 122 483.50 $32820.18 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 25.96 $1410.39 $54.32
PHY -97110 PT SESSION BY LICENSED PT 185 228 895.37 $60777.40 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 6.29 $341.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 47 48 48.00 $48.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 4 4 1.99 $37.23 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 416 501 2344.21 $159124.91 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 37 42 365.43 $4823.67 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 2 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 31 32 279.71 $139.86 $0.50
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Subtotal (Total Children Is Unduplicated) 781 1445 6521.26 $369659.01 $56.69
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Total 1456 6538.40 $371088.90 $56.76
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Number of Children (Unduplicated) With at Least One Authorization 783