Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 12.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 12.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 15 16.00 $776.00 $48.50
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 63 67 67.00 $3350.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 192 204 213.32 $10346.20 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 133 140 153.65 $7451.91 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 233 251 264.65 $12835.64 $48.50
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Subtotal (Total Children Is Unduplicated) 434 678 715.62 $34884.75 $48.75
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 9.57 $478.57 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 170 186 292.62 $14630.99 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 85 137.91 $6895.74 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 68 93.23 $4661.45 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 113 175.70 $8785.02 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.50 $12.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 7.50 $550.53 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 71 79 441.61 $11040.27 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 464 529 3018.63 $150931.72 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 258 295 1321.35 $89693.03 $67.88
PHY -97110 PT SESSION BY LICENSED PT 208 232 1029.04 $69850.96 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 18 11.74 $11.74 $1.00
SENS -V5264 EARMOLD 1 1 2.00 $37.44 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 29.11 $1455.47 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 303 342 1409.97 $95708.99 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.79 $36.77 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 11.57 $1157.14 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 400 481 2082.06 $1041.03 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 7 32.61 $1630.36 $50.00
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Subtotal (Total Children Is Unduplicated) 754 2466 10109.51 $458609.71 $45.36
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Total 3145 10837.14 $493494.47 $45.54
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Number of Children (Unduplicated) With at Least One Authorization 771