Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 4.00 $148.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 4.00 $148.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 7 8 8.00 $400.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 58 62.29 $3020.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 18 23 29.86 $1448.07 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 35 35 35.00 $1750.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 97 123 130.86 $6346.57 $48.50
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Subtotal (Total Children Is Unduplicated) 190 248 267.00 $13085.10 $49.01
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 8.43 $12649.95 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.25 $112.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 2 4.73 $118.34 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 102 127 164.58 $8229.19 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 54 89.85 $4492.50 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 47 67.95 $3397.50 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 123 161.00 $8050.01 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 10 47.14 $1178.58 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 137 184 774.07 $38703.42 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 17.29 $864.29 $50.00
INTR -INTR INTERPRETER 2 2 1.87 $93.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 73 79 469.69 $31882.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 19.21 $1043.33 $54.32
PHY -97110 PT SESSION BY LICENSED PT 74 85 374.53 $25422.93 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 7.97 $432.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 7.83 $7.83 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 252 321 1380.88 $93733.98 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 36.93 $487.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 333 503 183324.57 $91662.29 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 10 22.99 $1149.41 $50.00
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Subtotal (Total Children Is Unduplicated) 409 1586 186988.76 $323962.04 $1.73
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Total 1835 187259.76 $337195.14 $1.80
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Number of Children (Unduplicated) With at Least One Authorization 461