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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 50 52 53.00 $2570.50 $48.50
EVAL -EVAL DEVELOPMENTAL EVALUATION 14 14 14.00 $700.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 217 233 248.57 $12055.71 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 121 130 129.14 $6263.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 241 262 275.29 $13351.36 $48.50
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Subtotal (Total Children Is Unduplicated) 450 691 720.00 $34941.00 $48.53
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 12.00 $600.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 13 14 5.62 $281.11 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 2.26 $112.78 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.44 $72.22 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 9 3.39 $169.45 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 82 89 660.29 $16507.15 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 517 590 3471.78 $173589.19 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 318 357 1768.30 $120032.20 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.93 $213.40 $54.32
PHY -97110 PT SESSION BY LICENSED PT 225 249 1170.07 $79424.38 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 29 25.98 $25.98 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 9.98 $499.16 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 380 431 2102.40 $142711.16 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.57 $47.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 493 649 3030.38 $1515.19 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 11 12 33.23 $1661.66 $50.00
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Subtotal (Total Children Is Unduplicated) 810 2458 12305.63 $537535.58 $43.68
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Total 3149 13025.63 $572476.58 $43.95
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Number of Children (Unduplicated) With at Least One Authorization 829