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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 56 57 120.355556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 45 50 10.722223 $520.0300 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 1.094444 $65.6600 $60.0000
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 1 1 0.008333 $0.6200 $74.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 48 48 0.461104 $34.5300 $74.8900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 0.133331 $9.9800 $74.8700
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.661110 $32.0600 $48.4900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.355555 $17.2400 $48.4900
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 3.381745 $164.0100 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 124 133 17.001179 $864.1200 $50.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 23 7.344444 $11016.6000 $1499.9900
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 104 112 161.547619 $8077.3800 $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 87 94 475.719048 $23785.9600 $50.0000
INTR -INTR INTERPRETER 29 32 194.933334 $9746.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 19 105.295238 $7147.4500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 22 25 140.638093 $9546.5100 $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 1 1 0.311111 $155.5500 $499.9800
SENS -V5264 EARMOLD 3 4 1.144444 $20.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 32 230.885714 $15672.5200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 403 894 226424.801596 $113212.4000 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 453 2224 228669.871502 $245454.9600 $1.0700
-------------------------------------------------------------------------------------------------------------------------------------
Total 2414 228807.228237 $246319.0800 $1.0800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 555