Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 15.000000 $727.5000 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 6.000000 $300.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 130 140 140.000000 $6790.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 120 128 142.428572 $6907.7900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 100 104 119.571429 $5799.2100 $48.5000
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Subtotal (Total Children Is Unduplicated) 297 393 424.000001 $20569.5000 $48.5100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 3.882540 $194.1300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 6 2.077778 $103.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 2.122223 $106.1200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 44 44 270.571430 $6764.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 526 588 3500.850791 $175042.5300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 193 206 1133.657137 $76952.6600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 206 224 1042.428572 $70760.0500 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 14.533333 $14.5300 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 24.547620 $1227.3900 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 187 196 1008.571425 $68461.8500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.428571 $18.8600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 521 687 3458.404759 $1729.2000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 21.376191 $1068.8100 $50.0000
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Subtotal (Total Children Is Unduplicated) 731 1995 10485.452370 $402494.2900 $38.3900
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Total 2388 10909.452371 $423063.7900 $38.7800
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Number of Children (Unduplicated) With at Least One Authorization 741