Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 27.777777 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 27.777777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 28 6.555557 $317.9500 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 2.066667 $124.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.766668 $203.1800 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 1.800000 $87.3000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 1.277778 $61.9700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 2.666666 $129.3300 $48.5000
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Subtotal (Total Children Is Unduplicated) 53 60 16.133336 $923.7400 $57.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 2.150000 $10750.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.183333 $9.1700 $49.9900
CONIF -CONIF CONSULT ITDS, FACE TO FACE 244 244 388.808734 $19440.4600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 89 89 161.333336 $8066.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 121 121 213.592854 $10679.6300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 244 244 370.180166 $18509.0400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 236 1202.309521 $60115.5100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 13 13 81.876190 $4093.8300 $50.0000
INTR -INTR INTERPRETER 13 13 121.246032 $6062.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 51 399.176193 $27096.0900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 56 56 399.419040 $27112.6100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $605.2800 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.211111 $605.5500 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.366667 $83.6100 $228.0200
SENS -V5264 EARMOLD 8 8 5.266667 $94.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 76 541.084123 $36728.8200 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 414 808 223865.142860 $111932.5700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 9 42.604763 $2130.2400 $50.0000
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Subtotal (Total Children Is Unduplicated) 424 1980 227807.094447 $344116.1700 $1.5100
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Total 2055 227851.005560 $345039.9100 $1.5100
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Number of Children (Unduplicated) With at Least One Authorization 442