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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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 12 12 13.000000 $630.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 119 126 134.714286 $6533.6400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 94 101 101.000000 $4898.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 64 64 73.285715 $3554.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 244 303 322.000001 $15617.0000 $48.5000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.644444 $32.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 11 5.455555 $272.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 9.311112 $465.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 3.549998 $177.4900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 24 24 181.428569 $4535.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 515 567 3642.279387 $182113.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 161 171 962.357148 $65324.7300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 159 174 995.428572 $67569.6500 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 15 15.000000 $15.0000 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 10 10 19.217459 $960.8700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 117 122 724.928572 $49208.1100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.428571 $18.8600 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.285714 $28.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 529 682 3606.403191 $1803.2000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 8 8 37.152380 $1857.6200 $50.0000
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Subtotal (Total Children Is Unduplicated) 677 1809 10207.870672 $374534.0800 $36.6900
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Total 2112 10529.870673 $390151.0800 $37.0500
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Number of Children (Unduplicated) With at Least One Authorization 679