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 6 6 6.000000 $360.0000 $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 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 2 2 2.000000 $97.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 10.000000 $485.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 78 82 126.000000 $7298.7500 $57.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 18.000000 $27000.0000 $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 75 77 517.157152 $25857.8200 $50.0000
INTR -INTR INTERPRETER 25 44 238.461903 $11923.1000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 106.857145 $7253.4500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 14 15 78.185713 $5307.2600 $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 29 32 241.142859 $16368.7900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 289 433 180218.095237 $90109.0500 $0.5000
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Subtotal (Total Children Is Unduplicated) 443 1588 182984.415090 $260714.4700 $1.4200
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Total 1670 183110.415090 $268013.2200 $1.4600
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Number of Children (Unduplicated) With at Least One Authorization 473