Summary Report for FSPSAs Initiated During the Report Period Center: 53
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 6 6 6.000000 $291.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.000000 $120.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 6.000000 $750.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 12 12 20.000000 $1000.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 6 10.000000 $555.0000 $55.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.000000 $97.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 32 41 53.000000 $3451.5000 $65.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.000000 $6000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 40.457144 $2022.8600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 37 58.509523 $2925.4700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 9 11 9.500000 $237.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 15 16.100000 $805.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 43 47.233334 $2361.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 36 44.966667 $2248.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 5.000000 $125.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.571429 $39.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 8 80.309524 $2007.7400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 39.000000 $1950.0000 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.366667 $59.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 44 222.893646 $11144.6800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.022222 $1.1100 $49.9500
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.428571 $368.4900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.000000 $67.8800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.571429 $628.5600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 8.699999 $8.7000 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.043836 $67.8500 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 12.000000 $814.5600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.571429 $152.7400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 445.714286 $222.8600 $0.5000
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Subtotal (Total Children Is Unduplicated) 162 246 1072.959706 $34409.4400 $32.0700
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Total 287 1125.959706 $37860.9400 $33.6300
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Number of Children (Unduplicated) With at Least One Authorization 177