Summary Report for FSPSAs Ending During the Report Period Center: 52
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 2 2 1.833333 $110.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 6 7 7.000000 $350.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 34 41 41.000000 $1988.5000 $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 22 25 25.000000 $1212.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 24 26 26.000000 $1300.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 75 89 90.000000 $4365.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 138 194 194.833333 $9659.5000 $49.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 7 7.000000 $10500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.900000 $145.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 94 105 137.804760 $6890.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 70 102.190480 $5109.5400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 49 80.657145 $4032.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 125 173.019048 $8650.9600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 8 36.571427 $914.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 7 7.000000 $350.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 116 140 547.338095 $27366.9000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 49.428571 $2471.4300 $50.0000
INTR -INTR INTERPRETER 9 9 24.366667 $1218.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 57 283.364284 $19234.7700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 70 77 352.911903 $23955.6600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 3 4.857143 $263.8400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 5.744444 $5.7400 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -V5264 EARMOLD 1 1 1.666667 $30.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 17.142857 $857.1500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 180 211 716.645231 $48645.9600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 15.495238 $204.5400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 250 389 125661.023802 $62830.5100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 0.383333 $19.1700 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 13.928572 $696.4300 $50.0000
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Subtotal (Total Children Is Unduplicated) 321 1289 128244.439667 $225443.3000 $1.7600
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Total 1483 128439.273000 $235102.8000 $1.8300
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Number of Children (Unduplicated) With at Least One Authorization 357