Summary Report for FSPSAs Ending During the Report Period Center: 05
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.844444 $97.1100 $114.9900
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 12.000000 $1500.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 59 68 141.000000 $7050.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 109 109 218.000000 $16350.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 18 19 38.000000 $2850.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 63 64 128.000000 $9600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 79 80 160.000000 $8880.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 95 96 192.000000 $14400.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 18.000000 $873.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.000000 $291.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 15 16.000000 $776.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 276 497 954.844444 $64410.1100 $67.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 13 18.000000 $27000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 3.533333 $176.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 302 616 1252.428571 $62621.4300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 272 308 615.857143 $30792.8600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 97 105 210.347619 $10517.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 145 157 357.771428 $17888.5800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 201 224 449.857143 $22492.8600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 45 54 268.942860 $6723.5700 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.800000 $20.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 262 289 1626.114295 $81305.6500 $50.0000
INTR -INTR INTERPRETER 10 11 104.142857 $5207.1400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 41 164.595238 $11172.7100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 12.357143 $671.2400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 70 72 232.540475 $15784.8400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 4.714286 $256.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 26 42.428571 $42.4300 $1.0000
SENS -V5264 EARMOLD 1 1 0.844444 $15.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.357143 $17.8600 $49.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 121 129 571.507148 $38793.8700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 20.428572 $269.6600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 378 669 374563.376190 $187281.6900 $0.5000
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Subtotal (Total Children Is Unduplicated) 433 2730 380524.944459 $519151.6900 $1.3600
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Total 3227 381479.788903 $583561.8000 $1.5300
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Number of Children (Unduplicated) With at Least One Authorization 534