Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.79 $103.07 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 2.79 $103.07 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 2.00 $120.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.00 $250.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 13 16 16.00 $800.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 43 50 50.00 $2425.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 33 33.00 $1600.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 16 16 16.00 $800.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 74 84 84.00 $4074.00 $48.50
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Subtotal (Total Children Is Unduplicated) 151 203 204.00 $10118.00 $49.60
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 6.00 $300.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 49 54 67.46 $3372.86 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 29 35.33 $1766.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.30 $32.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 29 35.37 $1768.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 58 60.00 $3000.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.30 $32.50 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 12.29 $307.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 128 168 794.56 $39728.09 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 3.00 $150.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 70 77 474.39 $32201.64 $67.88
PHY -97110 PT SESSION BY LICENSED PT 93 107 530.01 $35977.39 $67.88
SENS -V5264 EARMOLD 1 1 0.40 $7.49 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.14 $107.15 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 208 242 1020.03 $69239.79 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 21.50 $283.80 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 310 485 178376.50 $89188.25 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 2.71 $135.72 $50.00
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Subtotal (Total Children Is Unduplicated) 368 1268 181450.30 $283699.31 $1.56
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Total 1472 181657.08 $293920.38 $1.62
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Number of Children (Unduplicated) With at Least One Authorization 405