Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 21 21 7.699998 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 7.699998 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.010959 $1.2700 $115.4300
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 0.672222 $32.6000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 1.805556 $87.5700 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.350000 $16.9800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.622222 $30.1800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 16 7.373015 $357.5900 $48.5000
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Subtotal (Total Children Is Unduplicated) 30 34 10.864111 $527.6900 $48.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.191781 $287.7000 $1500.1500
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.472146 $123.6100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 2.857687 $142.8800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.638814 $115.9700 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 23 23 9.827169 $491.3600 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 26 26 42.616665 $1065.4100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 15 17.666164 $883.3000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 13 16 23.299999 $582.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 7 3.833333 $191.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 9 14.649999 $366.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 18 13.325799 $666.2900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 15 15 23.183333 $579.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 11 66.519048 $3325.9500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 20 138.254762 $9384.7400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 7.857142 $426.8000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 7 8 39.197619 $2660.7300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 10.714286 $582.0000 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.202740 $13.1800 $64.9900
SENS -V5264 EARMOLD 1 1 0.010959 $0.2000 $18.0700
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 61 350.642855 $23801.6400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 239 359 126421.446823 $63210.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 251 607 127193.409123 $108902.4500 $0.8600
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Total 662 127211.973232 $109430.1400 $0.8600
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Number of Children (Unduplicated) With at Least One Authorization 273