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: 07-01-12 and 09-30-12 Date of Report: 11-15-12 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 0.177778 $6.5800 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.177778 $6.5800 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.000000 $145.5000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 31 34 51.694446 $2584.7300 $50.0000
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Subtotal (Total Children Is Unduplicated) 36 39 56.694446 $2960.2300 $52.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 12.231746 $611.5900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 22 2.439881 $121.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.644444 $16.1100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 46 122 214.204760 $10710.2000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 2.500000 $62.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 43 74.123807 $3706.1900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 48 80.023811 $4001.2000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 49 51 86.219045 $4310.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 9 10.582540 $264.5600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 28.423810 $710.6000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 25.571429 $1278.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 40 177.515079 $8875.7600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.133333 $6.6700 $49.9900
INTR -INTR INTERPRETER 2 2 5.266667 $263.3400 $50.0000
PHY -97110HM PT SESSION BY PT ASST 1 1 6.571429 $356.9600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 8.277779 $8.2800 $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
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 14.990476 $749.5200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 2.285714 $155.1500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.714286 $141.4300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 285 613 116670.511108 $58335.2600 $0.5000
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Subtotal (Total Children Is Unduplicated) 321 994 117444.364477 $100500.1200 $0.8600
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Total 1034 117501.236701 $103466.9300 $0.8800
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Number of Children (Unduplicated) With at Least One Authorization 322