Summary Report for FSPSAs Initiated During the Report Period Center: 03
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 -AUDE UNSPECIFIED AUDE SERVICES 29 30 30.000000 $1800.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.000000 $575.0000 $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 84 84 150.500000 $8352.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 8.500000 $637.5000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 6 6.000000 $291.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.000000 $436.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 7 7.000000 $339.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.000000 $727.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 36 36 36.000000 $1746.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 171 198 270.000000 $15065.2500 $55.8000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 12 22.000000 $33000.0000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 222 267 247.642857 $12382.1500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 1.750000 $43.7500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 206 211 443.358728 $22167.9200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 74 80 163.826986 $8191.3600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 101 108 207.338096 $10366.9100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 227 236 437.598414 $21879.9300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 208 218 1520.400019 $76019.9200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 24.476190 $1223.8100 $50.0000
INTR -INTR INTERPRETER 25 44 238.461903 $11923.1000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 47 51 413.571435 $28073.2100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 54 62 459.457142 $31187.9500 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 53 53 53.000000 $53.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.000000 $684.0000 $228.0000
SENS -V5264 EARMOLD 4 4 7.000000 $126.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 88 642.792857 $43632.7900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 291 436 181469.523808 $90734.7600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 11 95.142858 $4757.1400 $50.0000
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Subtotal (Total Children Is Unduplicated) 453 1891 186452.341293 $397447.6700 $2.1300
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Total 2089 186722.341293 $412512.9200 $2.2100
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Number of Children (Unduplicated) With at Least One Authorization 500