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: 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
Service Coordination, Class # 01
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.044444 $1.6400 $36.9600
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Subtotal (Total Children Is Unduplicated) 1 1 0.044444 $1.6400 $36.9600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 37 38 46.536508 $2792.1900 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.888889 $175.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 17 17 22.000000 $2530.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 2.142857 $267.8600 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 19 19 25.000000 $1250.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 15 27.000000 $2025.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 40.000000 $2220.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 4.428571 $214.7900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.000000 $533.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 13.285714 $644.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 114 155 214.282539 $13840.7000 $64.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 14 18.000000 $27000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 50.339682 $2516.9900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.500000 $25.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.377778 $9.4500 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 37 43 68.311110 $3415.5500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 4.900000 $122.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 26 39.566666 $1978.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 6 3.922223 $98.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 43 44.602382 $2230.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 5 4.900000 $122.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 55 73.709523 $3685.4700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 9.692063 $242.3000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 22.204763 $1628.0600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 20 20 56.266666 $1406.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 280 341 1613.306350 $80665.3200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 5.333333 $266.6700 $50.0000
INTR -INTR INTERPRETER 1 1 2.755556 $137.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 70.523811 $4787.1400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 22 25 159.371428 $10818.1300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 8 55.552381 $3017.6100 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 8.255554 $8.2600 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.000000 $1000.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.000000 $260.0000 $65.0000
SENS -V5264 EARMOLD 3 3 8.177778 $147.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 6.233333 $311.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 28 191.238099 $12981.2500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 6 36.714286 $484.6300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 177 330 41286.298406 $20643.1500 $0.5000
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Subtotal (Total Children Is Unduplicated) 349 1019 43847.053171 $180009.7700 $4.1100
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Total 1175 44061.380154 $193852.1100 $4.4000
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Number of Children (Unduplicated) With at Least One Authorization 351