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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 38 40 40.00 $1940.00 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 9 9 9.00 $450.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 208 225 257.86 $12506.07 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 121 132 132.43 $6422.79 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 226 250 282.14 $13683.93 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 425 656 721.43 $35002.78 $48.52
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.00 $550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 15 19.42 $970.95 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 5.46 $272.78 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.18 $8.89 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 15.64 $782.22 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 63 429.86 $10746.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 513 556 3606.40 $180319.85 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 306 337 1826.34 $123972.21 $67.88
PHY -97110 PT SESSION BY LICENSED PT 224 243 1292.53 $87737.03 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 29 24.41 $24.41 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 28.65 $1432.39 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 354 398 2062.81 $140023.85 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 514 633 3419.07 $1709.53 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 10 10 24.18 $1208.82 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 761 2323 12765.95 $549759.35 $43.06
-----------------------------------------------------------------------------------------------------------------------------
Total 2979 13487.38 $584762.13 $43.36
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 771