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: 10-01-12 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 37 38 1219.058730 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 38 1219.058730 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.355556 $21.3400 $60.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.866667 $99.6700 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.966667 $46.8800 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.294444 $4.4200 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 7 7 13.345880 $647.2800 $48.5000
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Subtotal (Total Children Is Unduplicated) 13 13 15.829214 $819.5800 $51.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.155556 $233.4000 $1500.4200
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 0.722222 $36.1100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 6 48.209523 $2410.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 17.857143 $446.4300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 117 132 768.633338 $38431.6300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 5.295238 $132.3800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 33 193.880954 $9694.0400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.285714 $7.1400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 88.666668 $4433.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.733333 $68.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 49 260.761908 $13038.0800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.714285 $67.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 87 528.985721 $26449.2600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.285714 $833.9500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 2 24.142857 $1638.8100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 1.857143 $100.8800 $54.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 14 121.000000 $8213.4700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 33.714286 $445.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 394 481 195360.857129 $97680.4300 $0.5000
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Subtotal (Total Children Is Unduplicated) 419 842 197472.758732 $204361.0300 $1.0300
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Total 893 198707.646676 $205180.6100 $1.0300
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Number of Children (Unduplicated) With at Least One Authorization 458