Summary Report for FSPSAs Ending During the Report Period Center: 57
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
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 11 11 11.000000 $569.3600 $51.7600
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.000000 $575.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 82 87 88.857143 $4309.5700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 104 106 125.886509 $6105.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 219 228 243.573810 $11813.3300 $48.5000
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Subtotal (Total Children Is Unduplicated) 303 439 476.317462 $23462.7600 $49.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 7.142857 $10714.3500 $1500.0100
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 0.861111 $43.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 29.192064 $1459.6000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 16.155556 $807.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 279 291 127.803178 $6390.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 0.900000 $22.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 44 44 269.714290 $6742.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 381 409 2719.000030 $135949.9700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 109 115 557.642858 $37852.7900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 134 140 589.535718 $40017.6400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 3.357143 $182.3600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 9.211111 $9.2100 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 16.339683 $816.9800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 253 269 1132.785722 $76893.4300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 20.142857 $265.8900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 421 488 5292.154000 $2646.0800 $0.5000
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Subtotal (Total Children Is Unduplicated) 576 1817 10791.938178 $320814.6600 $29.7300
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Total 2256 11268.255640 $344277.4100 $30.5500
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Number of Children (Unduplicated) With at Least One Authorization 581