Summary Report for FSPSAs Ending During the Report Period Center: 55
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 12 12 4.816668 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 12 12 4.816668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.066667 $64.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.155556 $132.8900 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 0.900000 $43.6500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 1.411111 $68.4400 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 8 11 4.533334 $308.9800 $68.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.060274 $301.5000 $5002.1600
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 20.860318 $1043.0200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 2.006393 $100.3200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 21 4.384093 $219.2000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 20 20 29.066670 $726.6800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 0.372603 $18.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.533333 $113.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 2.899998 $144.9900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 13 13 21.966670 $549.1800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 16 5.294445 $264.7300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 9.766668 $244.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 3 12.285713 $614.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 84.142857 $5711.6200 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.642857 $252.2000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 25.357142 $1721.2500 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.877778 $57.0600 $65.0000
SENS -V5264 EARMOLD 2 2 3.288889 $59.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 40 234.383338 $15909.9200 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 213 314 116732.460146 $58366.2300 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 214 486 117198.650185 $86417.4900 $0.7400
-------------------------------------------------------------------------------------------------------------------------------------
Total 509 117208.000187 $86726.4800 $0.7400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 226