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 -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.333333 $20.0000 $59.9900
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 40 45 40.678233 $2033.9100 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 0.046575 $2.3300 $50.0300
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Subtotal (Total Children Is Unduplicated) 47 52 45.324808 $2264.6700 $49.9700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 5.929985 $296.5000 $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 103 393 313.961685 $15697.9800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.827777 $70.6900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 26 31.819048 $1590.9600 $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 94 97 103.647616 $5182.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.638096 $40.9500 $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 15 16 71.074887 $3553.7400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 2 1.033333 $51.6700 $50.0000
INTR -INTR INTERPRETER 9 10 69.714285 $3485.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 18.714285 $1270.3300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 1 1 8.285714 $562.4300 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.066667 $1033.3500 $500.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 10 61.790477 $4194.3200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 314 788 193192.718214 $96596.3600 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 8.857143 $442.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 324 1421 193974.140323 $138032.8900 $0.7100
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Total 1488 194030.731799 $140297.5600 $0.7200
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Number of Children (Unduplicated) With at Least One Authorization 350