Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 10-01-11 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
EXIT -EXIT TRANSITION ASSESSMENT 4 5 5.000000 $250.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 37 44.428571 $2154.7900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 29 29.000000 $1406.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 27 27.000000 $1350.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 93 113 114.000000 $5529.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 151 213 221.428571 $10798.7900 $48.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 9 11.000000 $16500.0000 $1500.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 83 103 140.219042 $7010.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 57 82.033332 $4101.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 50 63.033332 $3151.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 118 185.490478 $9274.5300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 5 39.999999 $1000.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 7 10.928571 $546.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 4.428571 $221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 100 138 588.740473 $29437.0300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 9 38.785714 $1939.2900 $50.0000
INTR -INTR INTERPRETER 8 8 69.428572 $3471.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 42 210.300002 $14275.1600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 53 61 340.789288 $23132.7600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 5 13.857143 $752.7200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 4.366665 $4.3700 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 6.714286 $335.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 172 214 885.617455 $60115.7700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 7.888095 $104.1200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 241 366 128898.799984 $64449.4000 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 12.942857 $647.1400 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 294 1215 131616.363859 $240521.5400 $1.8300
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Total 1428 131837.792430 $251320.3300 $1.9100
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Number of Children (Unduplicated) With at Least One Authorization 324