Summary Report for FSPSAs Ending During the Report Period Center: 55
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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 6.00 $360.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 24 24 23.17 $1123.85 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 44 45 45.00 $2182.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 12 11.17 $541.85 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 30 30 30.00 $1455.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 81 87 86.04 $4173.15 $48.50
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Subtotal (Total Children Is Unduplicated) 125 206 203.39 $10002.76 $49.18
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 2.09 $104.41 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.45 $122.26 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.57 $78.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 5 6.73 $336.55 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 4.86 $121.43 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 10.43 $521.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 42 50 381.71 $19085.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 115 122 794.98 $53962.98 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 15.86 $861.36 $54.32
PHY -97110 PT SESSION BY LICENSED PT 64 67 336.99 $22875.05 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 6.43 $349.20 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 12.43 $621.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 171 188 1199.13 $81397.05 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 9.43 $124.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 37 44 2056.29 $1028.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 20.29 $1014.29 $50.00
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Subtotal (Total Children Is Unduplicated) 225 504 4867.65 $184354.08 $37.87
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Total 710 5071.03 $194356.84 $38.33
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Number of Children (Unduplicated) With at Least One Authorization 256