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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 13 14 5.666668 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.866667 $32.0700 $37.0000
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Subtotal (Total Children Is Unduplicated) 13 16 6.533335 $32.0700 $4.9100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 4.638888 $224.9800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.222222 $52.5400 $42.9900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 36 38 37.294444 $2237.6600 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 3.322222 $149.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 16 16.828571 $1935.2900 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.000000 $375.0000 $125.0000
EXIT -EXIT EXIT ASSESSMENT 34 34 31.113013 $1555.6500 $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 23 23 36.806393 $2760.4800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 0.044444 $3.3300 $74.9300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 28 37.873059 $2101.9500 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.285714 $110.8600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 21.775397 $1056.1100 $48.5000
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Subtotal (Total Children Is Unduplicated) 115 174 198.204367 $12713.3500 $64.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 11.085301 $16627.8000 $1499.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.144444 $78.8000 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.238889 $16.4500 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 32.822224 $1641.1200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 14 1.088893 $54.4700 $50.0200
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.016667 $0.4200 $25.0500
CONIF -CONIF CONSULT ITDS, FACE TO FACE 63 228 310.930161 $15546.5200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 1.305555 $32.6400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 32 59.377779 $2968.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 23 32.442857 $1622.1500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.600000 $15.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 54 97.323018 $4866.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.000001 $175.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 10 15.209525 $1115.1800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 20 82.914288 $2072.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 218 274 1126.435744 $56321.7500 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 10 10 13.058731 $652.9400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 13.038094 $885.0300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.857142 $263.8400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 11 11 50.741290 $3444.3300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 10 11 54.714285 $2972.0800 $54.3200
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 4 4 3.155556 $205.1100 $65.0000
SENS -V5264 EARMOLD 8 8 7.300000 $131.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 14.233334 $711.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 16 70.833333 $4808.1600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 16.714286 $220.6300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 246 638 97698.858662 $48849.4300 $0.5000
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Subtotal (Total Children Is Unduplicated) 276 1412 99729.440059 $167299.8300 $1.6800
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Total 1602 99934.177761 $180045.2400 $1.8000
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Number of Children (Unduplicated) With at Least One Authorization 300