Summary Report for FSPSAs Ending During the Report Period Center: 07
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 6.000000 $690.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 24.000000 $1800.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.000000 $300.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 15.000000 $727.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 28 32 61.000000 $4260.0000 $69.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 6 10.000000 $500.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 11 10.166667 $508.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 93 104 113.947618 $5697.3800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 10 11 11.500000 $287.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 29 38.528571 $1926.4300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 13.928571 $348.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 21.000000 $1050.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 58 58.614285 $2930.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 12 12 12.600000 $315.0000 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.400000 $60.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 88 99 647.595236 $32379.7700 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 12.857143 $872.7400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.714286 $93.1200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 7 7 14.147619 $960.3400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 4 14.000000 $760.4900 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 58 60 59.011112 $59.0100 $1.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 3 3 6.000000 $108.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 21 133.750000 $9078.9600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 28.714285 $379.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 13 15 80.142856 $40.0700 $0.5000
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Subtotal (Total Children Is Unduplicated) 281 483 1299.618249 $60650.1000 $46.6700
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Total 515 1360.618249 $64910.1000 $47.7100
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Number of Children (Unduplicated) With at Least One Authorization 291