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 12 12 14.000000 $679.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 6.000000 $750.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 113 115 225.750000 $11287.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 15 15 30.000000 $2250.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 30 60.000000 $4500.0000 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 170 206 393.750000 $23203.5000 $58.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 5.000000 $7500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 9.966667 $498.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 105 120 187.164285 $9358.2200 $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 10 11 20.066666 $501.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 11 16.100000 $805.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 32 46.261902 $2313.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 9 10.100000 $252.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 45 86.985713 $4349.2900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 24.423809 $610.5900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.000000 $75.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 23.523809 $1176.1900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 35 205.366670 $10268.3300 $50.0000
INTR -INTR INTERPRETER 72 112 201.130955 $10056.5300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 20.714286 $1406.0900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 6 7 33.542858 $2276.8800 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 66 68 81.531746 $81.5300 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 12 76.428572 $5187.9700 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 891 1197 5528.376217 $2764.1900 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 969 1738 6673.503198 $64912.3100 $9.7300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1944 7067.253198 $88115.8100 $12.4700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1029