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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 7.000000 $339.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.266667 $10.4200 $39.0800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.000000 $120.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 34 35 63.500000 $3175.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 49 52 81.766667 $4364.9200 $53.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 6.000000 $9000.0000 $1500.0000
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
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 15.285714 $382.1400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 23.285714 $1164.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 40 49 221.609519 $11080.4900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 5.447619 $272.3800 $50.0000
INTR -INTR INTERPRETER 2 2 4.377778 $218.8900 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 3 10.571428 $717.5900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 2.428571 $131.9200 $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 2 2 0.822222 $14.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.714286 $85.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 5.285714 $358.7900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.714286 $115.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 271 553 103276.569835 $51638.2900 $0.5000
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Subtotal (Total Children Is Unduplicated) 294 816 103935.336497 $93281.8400 $0.9000
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Total 868 104017.103164 $97646.7700 $0.9400
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Number of Children (Unduplicated) With at Least One Authorization 296