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: 10-01-12 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 46 46 106.133332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 46 46 106.133332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 41 16.344443 $792.7000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 14 14 9.311112 $558.6700 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.411111 $47.2800 $115.0000
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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.188889 $9.1600 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 4.205557 $203.9800 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.588889 $28.5600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 2.911111 $141.1900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 26 26 5.877778 $285.0700 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 0.161111 $16.1100 $99.9900
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Subtotal (Total Children Is Unduplicated) 186 214 40.941653 $2153.2300 $52.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 15 5.872222 $8808.3000 $1499.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 255 324 2.132008 $106.9200 $50.1500
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 9 0.023613 $0.6000 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 226 251 489.209524 $24460.4700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 113 132 232.796028 $11639.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 91 103 172.307932 $8615.3700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 238 260 459.657935 $22982.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 227 249 1821.119859 $91056.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 15 17 89.457144 $4472.8500 $50.0000
INTR -INTR INTERPRETER 25 27 246.869842 $12343.5000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 61 69 544.569843 $36965.4000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 49 55 361.147620 $24514.7000 $67.8800
SENS -FM FM RECEIVER HEARING AID 1 1 0.066667 $110.0600 $1650.8200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 0.727778 $363.9000 $500.0200
SENS -V5264 EARMOLD 7 9 3.683333 $66.3000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 90 689.463495 $46800.7900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 393 855 287093.633334 $143546.8200 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 24 27 138.866668 $6943.3400 $50.0000
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Subtotal (Total Children Is Unduplicated) 429 2495 292351.604845 $443797.9600 $1.5200
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Total 2755 292498.679830 $445951.1900 $1.5200
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Number of Children (Unduplicated) With at Least One Authorization 522