Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 10.142857 $375.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 10.142857 $375.2900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $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
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 5.000000 $242.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 21 23 40.000000 $2899.5000 $72.4900
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 3 4.000000 $200.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 9 10.433333 $521.6700 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 90 103 133.352379 $6667.6300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 16 17 27.542857 $688.5700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 49.829365 $2491.4700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 9 9 18.795238 $469.8800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 19.000000 $950.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 38 51.452380 $2572.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 6.000000 $150.0000 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 1.428571 $35.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 79 84 591.454759 $29572.7600 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 1.000000 $67.8800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.428571 $620.8000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 7 8 39.485713 $2680.3000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 13.714285 $744.9600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 47 47 47.077778 $47.0800 $1.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 17 102.999998 $6991.6500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.857142 $209.3200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 76 79 10914.228573 $5457.1100 $0.5000
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Subtotal (Total Children Is Unduplicated) 272 478 12065.080942 $61478.3900 $5.1000
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Total 502 12115.223799 $64753.1800 $5.3400
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Number of Children (Unduplicated) With at Least One Authorization 276