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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 56 57 120.355556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 56 57 120.355556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 47 52 11.116667 $539.1600 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 29 29 5.394445 $323.6700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.405556 $18.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.155556 $17.8900 $115.0300
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 0.027778 $2.0900 $75.0600
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.019444 $1.4600 $74.8300
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 70 70 0.683322 $51.1700 $74.8800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 22 22 0.211108 $15.8100 $74.8900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 3.772222 $182.9500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 2.788888 $135.2600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 37 38 9.287303 $450.4400 $48.5000
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Subtotal (Total Children Is Unduplicated) 227 249 33.862289 $1738.1400 $51.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 30 9.433332 $14149.8000 $1499.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 254 323 1.643119 $82.4700 $50.1900
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 9 0.023613 $0.6000 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 229 257 376.887305 $18844.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 92 105 154.674602 $7733.7300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 107 116 171.214285 $8560.7100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 263 293 393.577778 $19678.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 259 1336.395234 $66819.7800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 13 15 99.199999 $4960.0000 $50.0000
INTR -INTR INTERPRETER 29 32 194.933334 $9746.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 68 390.603172 $26514.1800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 64 73 500.117457 $33947.9700 $67.8800
SENS -FM FM RECEIVER HEARING AID 1 1 0.444444 $733.2600 $1649.8400
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 0.700000 $350.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.722222 $164.6600 $227.9900
SENS -V5264 EARMOLD 5 7 2.744444 $49.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 88 563.171427 $38228.1000 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 403 897 226842.801596 $113421.4000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 24 29 146.133334 $7306.6700 $50.0000
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Subtotal (Total Children Is Unduplicated) 469 2605 231185.420697 $371292.6600 $1.6100
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Total 2911 231339.638542 $373030.8000 $1.6100
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Number of Children (Unduplicated) With at Least One Authorization 611