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: 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 1.000000 $37.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 2 1.000000 $37.0000 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.266667 $10.4200 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 36 39 41.922223 $2515.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.000000 $225.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 22 22 26.044444 $2995.1100 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 4.000000 $500.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 36 37 67.500000 $3375.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 19 19 38.000000 $2850.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 42.000000 $2331.0000 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 12.142857 $588.9300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 12.857143 $623.5700 $48.5000
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Subtotal (Total Children Is Unduplicated) 125 168 261.733334 $16649.3700 $63.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 16.000000 $24000.0000 $1500.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.000000 $275.4400 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 59.366665 $2968.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 32 54.617461 $2730.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 36 64.785716 $3239.3000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 43 75.590477 $3779.5300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 44 48 77.763493 $3888.1900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.466667 $111.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 13 40.438096 $2964.9200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 10 34.566667 $864.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 23.285714 $1164.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 248 312 1540.806334 $77040.3400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 12 12 31.542857 $1577.1400 $50.0000
INTR -INTR INTERPRETER 2 2 4.377778 $218.8900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 69.280954 $4702.8000 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 17.571428 $954.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 12 14 85.923808 $5832.5000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 11 11 72.714286 $3949.8400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 8.633332 $8.6300 $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 5 5 5.000000 $325.0000 $65.0000
SENS -V5264 EARMOLD 9 9 8.700000 $156.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 26.728571 $1336.4300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 19 81.833333 $5554.8600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 28.571428 $377.1400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 271 555 103510.569835 $51755.2900 $0.5000
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Subtotal (Total Children Is Unduplicated) 313 1190 105950.134900 $200826.6400 $1.9000
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Total 1360 106212.868234 $217513.0000 $2.0500
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Number of Children (Unduplicated) With at Least One Authorization 317