Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $230.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 10.000000 $485.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.000000 $436.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 26 27 27.094444 $1314.0800 $48.5000
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Subtotal (Total Children Is Unduplicated) 40 48 49.094444 $2517.3400 $51.2800
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 0.500000 $25.0000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 18 17.003173 $850.1600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 34 29.372222 $1468.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 309 310 176.634118 $8831.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.477778 $11.9500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 156 156 1112.357937 $55617.9000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 45.071429 $3059.4500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 7 7 31.321429 $2126.1000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 0.928571 $50.4400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 9.955555 $9.9600 $1.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 3.500000 $175.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 48 50 357.961906 $24298.4600 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.214286 $148.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 421 445 10838.436502 $5419.2200 $0.5000
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Subtotal (Total Children Is Unduplicated) 467 1050 12638.734906 $102202.9200 $8.0900
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Total 1098 12687.829350 $104720.2600 $8.2500
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Number of Children (Unduplicated) With at Least One Authorization 476