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: 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 21 22 20.48 $993.44 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 32 32.00 $1552.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 16 15.33 $743.40 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 21.17 $1026.59 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 81 84 83.17 $4033.85 $48.50
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Subtotal (Total Children Is Unduplicated) 117 178 174.15 $8484.28 $48.72
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.50 $225.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 1.30 $65.00 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 5.93 $296.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.53 $13.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.38 $119.17 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.90 $45.00 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.53 $13.33 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 36.86 $1842.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 37 40 282.21 $14110.71 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 92 96 534.54 $36284.47 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 36.21 $1967.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 74 78 409.64 $27806.56 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 36.24 $1968.45 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.60 $2.60 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 171 181 1011.10 $68633.33 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 45.50 $600.60 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 99 133 4782.80 $2391.40 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 4 14.57 $728.58 $50.00
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Subtotal (Total Children Is Unduplicated) 248 571 7212.36 $160214.21 $22.21
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Total 749 7386.51 $168698.49 $22.84
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Number of Children (Unduplicated) With at Least One Authorization 272