Summary Report for FSPSAs Ending During the Report Period Center: 03
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.000000 $240.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 50 50 89.500000 $4967.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 5.500000 $412.5000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 13.000000 $630.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 7.000000 $339.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.000000 $242.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 30 30 30.000000 $1455.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 112 117 161.000000 $8707.2500 $54.0800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 25.000000 $37500.0000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 222 268 248.642857 $12432.1500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 1.750000 $43.7500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 190 207 347.871428 $17393.5700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 108 186.669844 $9333.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 104 116 187.046030 $9352.3000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 230 250 378.712698 $18935.6400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 70 75 464.838100 $23241.9000 $50.0000
INTR -INTR INTERPRETER 24 42 293.042857 $14652.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 15 98.000001 $6652.2300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 17 18 118.968252 $8075.5800 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 55 55.000000 $55.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 55 357.433330 $24262.6100 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 77 102 41983.809527 $20991.9100 $0.5000
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Subtotal (Total Children Is Unduplicated) 454 1325 44746.784924 $202922.2500 $4.5300
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Total 1442 44907.784924 $211629.5000 $4.7100
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Number of Children (Unduplicated) With at Least One Authorization 507