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: 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 4 4 7.444444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 7.444444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 5.669634 $340.1800 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.500000 $22.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.916667 $220.4200 $115.0000
EXIT -EXIT EXIT ASSESSMENT 10 10 10.644445 $532.2300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.367123 $27.5300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.006393 $225.4800 $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 8 8 2.440182 $135.4300 $55.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 2.588889 $125.5600 $48.5000
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Subtotal (Total Children Is Unduplicated) 31 44 27.177777 $1632.6500 $60.0700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.350000 $525.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 34.642857 $1732.1500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 13 0.088893 $4.4700 $50.2300
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 0.016667 $0.4200 $25.0500
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 173 412.555553 $20627.7700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 30.333334 $1516.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 24.834921 $1241.7500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 35.350000 $1767.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.200000 $55.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 4 10.076190 $738.7900 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 16.804762 $420.1200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 89 591.880416 $29594.0200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 3 3 13.347620 $667.3900 $50.0000
OCCT -97530HM OT SESSION BY OT ASST 1 1 9.714286 $527.6800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 25.093673 $1703.3600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 13.142857 $713.9200 $54.3200
SENS -V5264 EARMOLD 1 1 4.000000 $72.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.266667 $113.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 19.947619 $1354.0500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.571429 $152.7400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 99 236 66979.106342 $33489.5500 $0.5000
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Subtotal (Total Children Is Unduplicated) 104 580 68237.324086 $97017.6600 $1.4200
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Total 628 68271.946307 $98650.3100 $1.4400
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Number of Children (Unduplicated) With at Least One Authorization 107