Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 07-01-11 and 09-30-11 Date of Report: 11-30-11 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.428571 $89.8600 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 2.678571 $99.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.800000 $70.3400 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 46 46 47.733333 $2864.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 5.555555 $250.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 25 25 25.600000 $2944.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 7.000000 $875.0000 $125.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 5.000000 $375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 20 30.285714 $1680.8600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 1.000000 $50.0000 $50.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.000000 $150.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 15 15.000000 $727.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 20 20 20.000000 $970.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 62 63 63.000000 $3055.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 155 219 233.974602 $14578.2000 $62.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 11 35.642858 $53464.2000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 8 9 29.828572 $1491.4300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 32 57.819048 $2890.9600 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 3.000000 $75.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 9.466667 $473.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 44 57.447619 $2872.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 42 49.505479 $2475.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 9.333333 $233.3300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 38.239683 $2803.7300 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.285714 $107.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 26 27 69.533333 $1738.3300 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.285714 $407.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 273 331 1502.295223 $75114.8500 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 1.233333 $61.6700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 23.042857 $1152.1500 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 171.714283 $11655.9700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 10 13 91.285715 $4958.6400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 31 32 218.409522 $14825.6500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 11 12 77.499999 $4209.8100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 9.804763 $9.8000 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.117808 $267.6600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 4.000000 $912.0000 $228.0000
SENS -V5264 EARMOLD 8 9 11.255556 $202.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 9 12.852380 $642.6200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 38 232.999998 $15816.0500 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.428571 $240.5600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 12 14 76.095239 $1004.4600 $13.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 347 717 2828.423267 $200350.5900 $70.8300
-------------------------------------------------------------------------------------------------------------------------------------
Total 939 3065.076440 $215027.8900 $70.1500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 360