Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 14 14.00 $679.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 61 66 80.71 $4035.72 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 159 186 201.75 $9784.99 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 113 134 135.37 $6565.29 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 200 227 250.14 $12131.93 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 383 628 682.98 $33246.92 $48.68
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 7.00 $350.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 182 193 289.62 $14481.22 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 82 85 123.86 $6192.87 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 61 93.66 $4683.11 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 112 117 159.30 $7965.01 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 3.59 $263.50 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 92 126 540.44 $13511.05 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 467 594 2946.11 $147305.48 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 235 285 1068.71 $72543.76 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 10.71 $582.00 $54.32
PHY -97110 PT SESSION BY LICENSED PT 202 252 1052.71 $71458.22 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 6 6 2.67 $2.67 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 13 30.29 $1514.53 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 277 328 1244.61 $84484.12 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.29 $728.57 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 384 445 1766.61 $883.30 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 10 26.48 $1324.06 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 710 2532 9373.66 $428273.44 $45.69
-----------------------------------------------------------------------------------------------------------------------------
Total 3160 10056.64 $461520.36 $45.89
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 727