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: 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
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 1 1 1.00 $60.00 $60.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 18 18.00 $873.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 35 36 36.00 $1746.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 28.00 $1358.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 87 88 87.61 $4249.14 $48.50
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Subtotal (Total Children Is Unduplicated) 116 180 179.61 $8701.24 $48.44
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.00 $4500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 10.71 $535.72 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 2 0.56 $13.96 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 841.71 $21042.86 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 33.29 $1664.29 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 34 36 228.95 $11447.39 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.14 $7.15 $50.00
INTR -INTR INTERPRETER 1 1 4.57 $228.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 109 112 674.38 $45776.64 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 4.93 $267.72 $54.32
PHY -97110 PT SESSION BY LICENSED PT 63 63 349.57 $23728.74 $67.88
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 177 189 1143.93 $77649.85 $67.88
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 57 69 4222.86 $2111.43 $0.50
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Subtotal (Total Children Is Unduplicated) 242 489 7519.59 $189024.29 $25.14
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Total 669 7699.20 $197725.53 $25.68
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Number of Children (Unduplicated) With at Least One Authorization 272