Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 10-01-12 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 1 1 3.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 3.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.083333 $4.0400 $48.4800
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 0.175342 $8.5000 $48.4900
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Subtotal (Total Children Is Unduplicated) 2 2 0.258675 $12.5400 $48.4900
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.500000 $25.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 41.714284 $2085.7200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 7 40.495239 $2024.7700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 19.714286 $985.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 18.333334 $916.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 33.857142 $1692.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 28 274.414284 $13720.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.366667 $68.3400 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 4 4 43.857143 $2977.0200 $67.8800
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 70.857142 $4809.7800 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 23 26 11461.714285 $5730.8600 $0.5000
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Subtotal (Total Children Is Unduplicated) 36 88 12007.823806 $35055.4400 $2.9200
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Total 91 12011.082481 $35067.9800 $2.9200
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Number of Children (Unduplicated) With at Least One Authorization 37