Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 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
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 17 18 18.00 $900.00 $50.00
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 80 80 134.29 $10071.43 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 39 40 59.00 $4425.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 21 21 27.53 $2065.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 98 103 162.29 $9006.86 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 13.50 $1012.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 9 9 9.00 $436.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.00 $145.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 14 15 15.00 $727.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 154 302 446.60 $29169.38 $65.31
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 14.00 $21000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.23 $61.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 3.50 $175.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.00 $25.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 8 6.75 $337.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 13.29 $332.14 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 13.37 $668.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.45 $136.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.92 $45.84 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 13 11.35 $567.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 9 7.67 $191.67 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 611.43 $7642.86 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 48 51 314.17 $15708.58 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 13.71 $685.72 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 36 37 201.53 $13679.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 15 15 78.15 $4245.30 $54.32
PHY -97110 PT SESSION BY LICENSED PT 16 19 86.61 $5878.89 $67.88
PHY -97110HM PT SESSION BY PT ASST 13 15 46.28 $2513.86 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 60 436.63 $29638.36 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 20 20 129.11 $1704.24 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 14.00 $1400.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 3.29 $164.29 $50.00
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Subtotal (Total Children Is Unduplicated) 154 301 2022.43 $107671.47 $53.24
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Total 604 2470.03 $136840.85 $55.40
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Number of Children (Unduplicated) With at Least One Authorization 274