Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 01-01-12 and 03-31-12 Date of Report: 05-15-12 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 48 48 48.200000 $2892.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 7.133333 $321.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 20 20 21.888889 $2517.2200 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 13 13.000000 $1625.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 8 8 10.000000 $500.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 5.000000 $375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 18 35.571429 $1974.2100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.000000 $200.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.000000 $242.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 6.000000 $291.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 33 34 34.000000 $1649.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 133 179 203.793651 $13527.9300 $66.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 11 21.142857 $31714.3500 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 21.323810 $1066.1900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.500000 $75.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 36 43 75.769046 $3788.4500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 9 11 9.500000 $237.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 18 27.600001 $1380.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 3.655556 $91.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 44 52.957144 $2647.8600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 64 72.706132 $3635.3100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 7.433333 $185.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 7 8.603175 $630.7900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 34 155.276189 $3881.9100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 41.999999 $2100.0100 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 274 353 1651.853979 $82592.6900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 7 24.042857 $1202.1500 $50.0000
INTR -INTR INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 88.642858 $6017.0800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 23.000000 $1249.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 29 34 255.714286 $17357.8800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 13 60.857142 $3305.7600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 10.549206 $10.5500 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5264 EARMOLD 7 7 6.377778 $114.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 11 15.431745 $771.5900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 53 313.271427 $21264.8800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 60.857142 $803.3200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 35 46 4090.942858 $2045.4700 $0.5000
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Subtotal (Total Children Is Unduplicated) 355 832 7110.008520 $188543.9500 $26.5200
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Total 1011 7313.802171 $202071.8800 $27.6300
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Number of Children (Unduplicated) With at Least One Authorization 376