Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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 2 2 1.10 $40.70 $37.00
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Subtotal (Total Children Is Unduplicated) 2 2 1.10 $40.70 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 2.80 $168.01 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 4.57 $228.57 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 21.00 $1575.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 6 6 10.00 $750.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 21 22 38.00 $2850.00 $75.00
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 11 11 11.00 $533.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.00 $582.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 22 23 33.29 $1614.36 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 3 3 3.00 $150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 74 111 152.66 $9622.93 $63.04
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 7.33 $366.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 73 78 115.69 $5784.68 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 55 96.93 $4846.49 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.77 $19.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 51 98.91 $4945.60 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.12 $77.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 67 76 107.21 $5360.36 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 110.00 $2750.00 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 10.14 $253.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 104 108 686.91 $34345.74 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 3.73 $186.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 91 101 727.69 $49395.67 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.43 $783.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 80 85 654.27 $44411.96 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 39.28 $2133.48 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 3.57 $178.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 135 147 1023.79 $69494.89 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.71 $419.04 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 71.36 $941.92 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 9 13 1049.14 $524.57 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 1.43 $71.43 $50.00
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Subtotal (Total Children Is Unduplicated) 250 745 4835.42 $227366.58 $47.02
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Total 858 4989.18 $237030.21 $47.51
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Number of Children (Unduplicated) With at Least One Authorization 289