Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.00 $27.10 $27.10
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 26 26 24.46 $1186.09 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 31 31.00 $1503.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 14 12.39 $600.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 27.35 $1326.48 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 89 92 92.22 $4472.51 $48.50
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Subtotal (Total Children Is Unduplicated) 120 195 191.41 $9296.54 $48.57
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 20.14 $1007.15 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 1.80 $90.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.55 $27.50 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 226.29 $5657.15 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 10.86 $542.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 40 262.07 $13103.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 90 93 585.22 $39724.49 $67.88
PHY -97110 PT SESSION BY LICENSED PT 66 69 442.92 $30065.32 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 2.93 $159.16 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 3.07 $3.07 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 175 1012.89 $68754.99 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.43 $18.86 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 61 72 2615.64 $1307.82 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 8.29 $414.29 $50.00
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Subtotal (Total Children Is Unduplicated) 231 470 5195.07 $162375.98 $31.26
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Total 665 5386.49 $171672.52 $31.87
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Number of Children (Unduplicated) With at Least One Authorization 260