Summary Report for FSPSAs Ending During the Report Period Center: 54
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 15 15 11.266668 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 11.266668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.266667 $109.9400 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 0.016667 $0.9500 $57.0500
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 12 5.295052 $317.6900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.288888 $13.0000 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.866667 $329.6700 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 44 53 53.748074 $2687.4000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.273581 $320.5100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.566438 $31.4400 $55.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 9.661112 $468.5700 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.172222 $8.3500 $48.4900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 1.872222 $90.8000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 18 41.856350 $2030.0400 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 0.224353 $11.2200 $50.0100
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Subtotal (Total Children Is Unduplicated) 91 114 124.174960 $6472.8100 $52.1300
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 6.274429 $313.7200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 28 37.541269 $1877.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 1.148413 $28.7100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 104 398 316.489465 $15824.3800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.827777 $70.6900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 31 41.885714 $2094.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.466667 $11.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 28 36.476191 $1823.8100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 100 103 111.369839 $5568.4900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.638096 $40.9500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.866667 $121.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.066667 $51.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 4.428571 $221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 235 253 1486.046334 $74302.2700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 9 37.861905 $1893.0900 $50.0000
INTR -INTR INTERPRETER 9 10 69.714285 $3485.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 35 244.714284 $16611.2100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 41 44 280.514285 $19041.3000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 24.000000 $1303.6800 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.066667 $1033.3500 $500.0100
SENS -V5264 EARMOLD 4 4 3.177777 $57.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 64 353.031749 $23963.7800 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 11.285714 $613.0400 $54.3200
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 323 815 202179.099166 $101089.5500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 3 3 14.285715 $714.2900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 5 33.285715 $1664.2800 $50.0000
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Subtotal (Total Children Is Unduplicated) 340 1853 205306.563361 $273821.2800 $1.3300
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Total 1982 205442.004989 $280294.0900 $1.3600
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Number of Children (Unduplicated) With at Least One Authorization 369