Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 24.000000 $1164.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 9.066667 $544.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 6.000000 $270.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 11.122223 $1279.0600 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 5.000000 $625.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 26 28 56.000000 $7000.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 147 156 306.750000 $15337.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 50.000000 $3750.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 21 42.000000 $3150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 25 25 50.000000 $2775.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 196 196 392.500000 $29437.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 72 72 144.000000 $10800.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 183 183 366.000000 $20313.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 224 247 494.500000 $37087.5000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.000000 $242.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.000000 $582.0000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.000000 $30.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 25 25 37.714286 $1829.1400 $48.5000
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Subtotal (Total Children Is Unduplicated) 610 1049 2021.653176 $136763.2100 $67.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 19 25.000000 $37500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 19 20 26.023810 $1301.1900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 115 132 201.914285 $10095.7200 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 7 8 6.400000 $160.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 42 45 85.419043 $4270.9400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 11 12 21.166666 $529.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 12 18.500000 $925.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 34 48.361902 $2418.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 10 10 11.133333 $278.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 50 97.228570 $4861.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 26.957142 $673.9300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.714286 $117.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 29 194.285710 $4857.1500 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 41.523809 $2076.1900 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 15.000000 $375.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 563 608 3406.361927 $170318.0100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 18.704762 $935.2400 $50.0000
INTR -INTR INTERPRETER 72 112 201.130955 $10056.5300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 20 106.028573 $7197.2100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.214286 $174.6000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 97 104 536.652387 $36427.9600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 4 31.285714 $1699.4400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 72 74 87.531746 $87.5300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 7 7 11.000000 $5500.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 9.153425 $594.9700 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 2 2 2.000000 $228.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 8 9 16.677778 $300.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 14.500000 $725.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 176 189 1148.400005 $77953.3500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 45.285714 $597.7700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 918 1236 5703.780980 $2851.9000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 31.000001 $1550.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1040 2782 12198.336809 $388093.6900 $31.8200
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Total 3831 14219.989985 $524856.9000 $36.9100
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Number of Children (Unduplicated) With at Least One Authorization 1275