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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 7.194444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 7.194444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 2.827779 $137.1500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 1.522222 $73.8300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 11.967460 $580.4200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 1.150000 $55.7700 $48.5000
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Subtotal (Total Children Is Unduplicated) 18 25 17.467461 $847.1800 $48.5000
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.050000 $2.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 22 12.114285 $605.7100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 13.588889 $679.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 11.000791 $550.0300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 99 107 577.192850 $28859.6400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 32.071428 $2177.0100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 6 6 29.500000 $2002.4600 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 5.421429 $271.0700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 10.285714 $698.1900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 559 701 4742.206323 $2371.1000 $0.5000
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Subtotal (Total Children Is Unduplicated) 576 887 5433.431709 $38217.1500 $7.0300
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Total 923 5458.093614 $39064.3200 $7.1600
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Number of Children (Unduplicated) With at Least One Authorization 592