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 5 5 4.033333 $195.6200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.222222 $52.5400 $42.9900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.000000 $120.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 34 34 31.113013 $1555.6500 $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 1 1 2.000000 $111.0000 $55.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 2.700000 $130.9500 $48.5000
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Subtotal (Total Children Is Unduplicated) 44 47 46.068568 $2430.7600 $52.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 3.118265 $4677.3000 $1499.9700
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 30 31 56.877779 $2843.8900 $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 3 3 3.266667 $239.5100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 5 40.066667 $1001.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 30 36 159.480953 $7974.0400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.142857 $57.1500 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 1.571428 $106.6700 $67.8800
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 2 2 4.177777 $75.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.533333 $226.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 1.285714 $87.2700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.142857 $15.0900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 244 633 96926.191995 $48463.1000 $0.5000
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Subtotal (Total Children Is Unduplicated) 254 1068 97691.541224 $90926.1300 $0.9300
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Total 1131 97744.143127 $93388.9500 $0.9600
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Number of Children (Unduplicated) With at Least One Authorization 266