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: 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 3 3 12.000000 $540.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 4.000000 $460.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 10 10 20.000000 $1000.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.000000 $145.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.000000 $194.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 24 27 46.000000 $2485.0000 $54.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.000000 $6000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 28 31 40.549206 $2027.4700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 93 89.035714 $4451.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 24 25 18.321429 $458.0400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 22 22 28.971432 $1448.5900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.700000 $117.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 25 44.052382 $2202.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.500000 $37.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 33.564284 $1678.2100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.700000 $117.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 40 56.754763 $2837.7500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.100000 $152.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 218 1376.988893 $68849.4000 $50.0000
INTR -INTR INTERPRETER 60 72 283.629762 $14181.4900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 88 100 456.607143 $30994.4800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 4.642858 $252.2000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 100 104 441.088092 $29941.1100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 8.642857 $469.4800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 35 35 35.000000 $35.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 4 4 4.000000 $2000.0000 $500.0000
SENS -V5264 EARMOLD 4 4 3.555556 $64.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 214 232 1092.765085 $74176.8600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 7 8 63.714286 $841.0300 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.000000 $100.0000 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 337 453 159527.619035 $79763.8100 $0.5000
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Subtotal (Total Children Is Unduplicated) 553 1510 163631.502777 $323198.3200 $1.9800
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Total 1537 163677.502777 $325683.3200 $1.9900
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Number of Children (Unduplicated) With at Least One Authorization 562