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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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 14 15 17.86 $866.07 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 85 91 93.94 $4696.91 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 135 147 147.00 $7129.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 103 109 139.34 $6758.13 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 187 201 214.80 $10418.03 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 8.57 $428.57 $50.00
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Subtotal (Total Children Is Unduplicated) 390 566 622.51 $30347.20 $48.75
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 13.57 $678.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 203 212 306.54 $15327.14 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 84 86 107.11 $5355.25 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 34 40.86 $2042.86 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 125 171.29 $8564.50 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 13.71 $1006.90 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 116 125 402.07 $10051.78 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 5.43 $271.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 417 464 2598.42 $129921.11 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 213 242 901.44 $61189.93 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.00 $651.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 196 220 864.07 $58653.15 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.29 $341.44 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 21 10.33 $10.33 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 33.59 $1679.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 279 320 1295.20 $87917.94 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 2 2 7.20 $720.47 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 376 457 1544.29 $772.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 20.39 $1019.28 $50.00
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Subtotal (Total Children Is Unduplicated) 684 2351 8354.79 $386193.84 $46.22
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Total 2917 8977.31 $416541.04 $46.40
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Number of Children (Unduplicated) With at Least One Authorization 710