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
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Subtotal (Total Children Is Unduplicated) 1 1 0.250000 $9.2500 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.000000 $120.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
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 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 6.000000 $291.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 24 29 30.000000 $1791.0000 $59.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071429 $107.1000 $1499.3900
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 22.661905 $1133.1000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 30 31 56.819048 $2840.9600 $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 1 1 0.811111 $59.4700 $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 4 4 19.509524 $487.7400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 54 61 273.490475 $13674.5400 $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 1 1 2.866667 $143.3400 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 5.285715 $358.7900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $605.2800 $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
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.233333 $61.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 6.428571 $436.3700 $67.8800
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Subtotal (Total Children Is Unduplicated) 176 242 554.515351 $26658.9500 $48.0800
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Total 272 584.765351 $28459.2000 $48.6700
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Number of Children (Unduplicated) With at Least One Authorization 185