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) 2 2 2.000000 $103.5200 $51.7600
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 23.857143 $1157.0700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 15.000000 $727.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 47 48 46.001587 $2231.0700 $48.5000
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Subtotal (Total Children Is Unduplicated) 62 87 86.858730 $4219.1600 $48.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
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 278 290 127.608734 $6380.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 0.900000 $22.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 143 155 1043.928582 $52196.4100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 16 47.642856 $3234.0000 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 21 21 83.714288 $5682.5200 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 9.211111 $9.2100 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.004762 $200.2400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 86 88 446.035716 $30276.8900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 418 484 5257.439714 $2628.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 472 1104 7067.694494 $104441.3700 $14.7800
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Total 1191 7154.553224 $108660.5300 $15.1900
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Number of Children (Unduplicated) With at Least One Authorization 483