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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 15.000000 $675.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.000000 $690.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 8 8 16.000000 $800.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.000000 $145.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 20 26 43.000000 $2456.0000 $57.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 7.000000 $10500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 33 35 57.996825 $2899.8400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 92 87.785714 $4389.2900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 24 25 18.321429 $458.0400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 8 8 10.400000 $520.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 31 47.771430 $2388.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.333333 $33.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 17 23.200001 $1160.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.500000 $137.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 28 45.952382 $2297.6300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.666667 $141.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 31.142857 $778.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 188 198 1231.552388 $61577.6100 $50.0000
INTR -INTR INTERPRETER 64 77 265.715477 $13285.7700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 70 81 339.778569 $23064.1600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 112 127 487.569051 $33096.1900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 0.857143 $46.5600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 50 54 54.000000 $54.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 6.000000 $3000.0000 $500.0000
SENS -V5264 EARMOLD 8 8 4.477778 $80.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 202 226 1032.092852 $70058.4400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 11 12 187.428568 $2474.0600 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 8 9 93.000000 $46.5000 $0.5000
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Subtotal (Total Children Is Unduplicated) 598 1049 4045.542464 $232588.3200 $57.4900
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Total 1075 4088.542464 $235044.3200 $57.4900
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Number of Children (Unduplicated) With at Least One Authorization 600