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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 10 10 10.00 $485.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 20 20 20.00 $1000.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 200 231 255.29 $12381.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 128 140 140.71 $6824.64 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 238 285 303.71 $14730.14 $48.50
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Subtotal (Total Children Is Unduplicated) 418 687 730.71 $35471.14 $48.54
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 7 8 8.00 $400.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 68 74 131.50 $6574.99 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.07 $1.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 24 37.31 $1865.56 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 31.00 $1549.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 54 59 96.84 $4842.21 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.83 $45.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 47 65 230.07 $5751.80 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 511 579 3192.59 $159629.46 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 286 335 1498.25 $101701.20 $67.88
PHY -97110 PT SESSION BY LICENSED PT 215 242 1057.36 $71773.89 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.43 $23.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 28 26.11 $26.11 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 21.12 $1056.19 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 1.43 $71.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 350 424 1803.29 $122407.13 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 430 516 2553.49 $1276.74 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 12 14 42.25 $2112.26 $50.00
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Subtotal (Total Children Is Unduplicated) 784 2395 10732.94 $481109.57 $44.83
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Total 3082 11463.66 $516580.71 $45.06
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Number of Children (Unduplicated) With at Least One Authorization 795