Summary Report for FSPSAs Ending During the Report Period Center: 55
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 16 16 10.864286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 10.864286 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 1.366668 $66.2900 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.350000 $16.9800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.372222 $18.0500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 15 8.378571 $406.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 27 27 10.497598 $509.1800 $48.5000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 0.596575 $29.8300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 0.010960 $0.5400 $49.2700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 3 0.505480 $12.6400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 16 9.944672 $497.2300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 22 22 32.566667 $814.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 15 5.852513 $292.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 16 16.799999 $420.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 0.616666 $30.8300 $49.9900
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.100000 $127.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 4.305554 $215.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 16.600000 $415.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 40.519047 $2025.9500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 20 97.250003 $6601.3300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 13.857144 $752.7200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 11 12 60.999999 $4140.6800 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.493151 $246.6000 $500.0500
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.049315 $3.2000 $64.9800
SENS -V5264 EARMOLD 1 1 0.246575 $4.4400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 65 73 394.107144 $26752.0100 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 239 346 111909.348320 $55954.6700 $0.5000
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Subtotal (Total Children Is Unduplicated) 249 575 112609.769784 $99337.2200 $0.8800
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Total 618 112631.131668 $99846.4000 $0.8900
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Number of Children (Unduplicated) With at Least One Authorization 270