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: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 3 3 3.000000 $180.0000 $60.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 17 17 24.000000 $1200.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 7.000000 $388.5000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 31 33 43.000000 $2283.0000 $53.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 29.809523 $1490.4800 $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 29 33 49.307937 $2465.4100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 5.266667 $131.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 18 30.933333 $1546.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.133333 $28.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 54 71.267461 $3563.3700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 7.833333 $195.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 43 46 93.719047 $4685.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 11.571429 $289.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 24.138095 $603.4500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.142857 $57.1500 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.700000 $17.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 39 45 196.342856 $9817.1500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 4.733333 $236.6700 $50.0000
INTR -INTR INTERPRETER 1 1 2.666667 $133.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 7.571429 $513.9500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 4 23.428571 $1590.3300 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 13 6.077778 $6.0800 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.208219 $78.5300 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 12.419047 $843.0000 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 131 217 44297.042860 $22148.5200 $0.5000
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Subtotal (Total Children Is Unduplicated) 228 477 44886.313775 $55117.6400 $1.2300
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Total 510 44929.313775 $57400.6400 $1.2800
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Number of Children (Unduplicated) With at Least One Authorization 231