Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 22.000000 $1067.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $39.0800 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 9.142857 $548.5700 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.000000 $135.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.000000 $460.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 3 3 5.000000 $625.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 27 29 57.000000 $7125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 170 178 350.750000 $17537.5000 $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 71 71 142.000000 $10650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 182 182 364.000000 $20202.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 222 245 490.500000 $36787.5000 $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 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 8.000000 $388.0000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 14 34.571429 $1676.7100 $48.5000
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Subtotal (Total Children Is Unduplicated) 599 1036 2038.464286 $137109.8700 $67.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 23 38.142857 $57214.3500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 11.593652 $579.6900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 120 136 208.038094 $10401.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 45 48 103.890475 $5194.5300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 12 12 15.914286 $397.8600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 13 17.571429 $878.5700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 31 48.685713 $2434.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 8 16.814285 $420.3600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 45 50 115.823810 $5791.2000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 14 14 21.685713 $542.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 18 133.428571 $3335.7200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.714286 $585.7200 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.428571 $210.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 541 567 3326.031772 $166301.5100 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 39.428571 $1971.4300 $50.0000
INTR -INTR INTERPRETER 64 106 330.292856 $16514.6400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 21 137.614286 $9341.2500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.214286 $174.6000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 82 89 710.047620 $48198.0200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 22.000000 $1195.0400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 42 42 45.304762 $45.3000 $1.0000
SENS -FM FM RECEIVER HEARING AID 1 1 1.000000 $1650.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.000000 $2000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.306241 $214.9100 $65.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5264 EARMOLD 5 5 8.422222 $151.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 32.428572 $1621.4300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 138 142 993.033338 $67407.0300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 32.571429 $429.9400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 765 1110 5583.469877 $2791.7400 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 17.428572 $871.4300 $50.0000
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Subtotal (Total Children Is Unduplicated) 850 2475 12045.326146 $409055.8800 $33.9600
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Total 3511 14083.790432 $546165.7500 $38.7800
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Number of Children (Unduplicated) With at Least One Authorization 992