Summary Report for FSPSAs Initiated During the Report Period Center: 02
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $230.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 35 35 70.000000 $3500.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.500000 $262.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 9 15.500000 $860.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 64 64 110.500000 $8287.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 48 48 78.000000 $5850.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 2.500000 $187.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 54.000000 $2997.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 47 47 82.533333 $6190.0000 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 7.000000 $339.5000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 149 265 456.533333 $30898.2500 $67.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 10.000000 $15000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.000000 $100.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 26 27.505480 $1375.2700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 3.500000 $87.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 24 29.366666 $1468.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 14.466667 $723.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.466667 $73.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 21 27.666667 $1383.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.683333 $17.0800 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 165.714286 $2071.4300 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 8 181.428571 $4535.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 79 83 553.071431 $27653.5400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 14.571429 $728.5700 $50.0000
INTR -INTR INTERPRETER 6 9 11.000000 $550.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 92.119046 $6253.0300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 3.285714 $178.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 33 34 186.726188 $12674.9700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 1.000000 $54.3200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.000000 $8.0000 $1.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 55 361.178573 $24516.7900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.928571 $12.2600 $13.2000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 13.214285 $660.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 179 334 1710.893574 $100161.9900 $58.5400
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Total 599 2167.426907 $131060.2400 $60.4700
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Number of Children (Unduplicated) With at Least One Authorization 247