Summary Report for FSPSAs Initiated During the Report Period Center: 02
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 -AUDE UNSPECIFIED AUDE SERVICES 3 3 3.00 $180.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EXIT -EXIT TRANSITION ASSESSMENT 22 23 23.00 $1150.00 $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 81 81 135.29 $10146.43 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 39 58.00 $4350.00 $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
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 10 10 10.00 $485.00 $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 4 4 4.00 $194.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 9 9 9.00 $436.50 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
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Subtotal (Total Children Is Unduplicated) 149 309 453.60 $29553.88 $65.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.00 $7500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 4.36 $217.86 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 2.30 $57.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 6 9 9.05 $452.50 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 6.90 $172.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.50 $275.00 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 3.25 $81.25 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.50 $25.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 11.28 $564.17 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 10 10 8.23 $205.83 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 1899.43 $23742.86 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 64 64 365.21 $18260.69 $50.00
INTR -INTR INTERPRETER 2 2 5.00 $250.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 31 32 191.37 $12990.28 $67.88
OCCT -97530HM OT SESSION BY OT ASST 12 12 69.83 $3793.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 19 22 160.98 $10927.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 9 48.54 $2636.71 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.00 $5.00 $1.00
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 59 64 406.45 $27589.63 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.29 $667.36 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 82.32 $1086.61 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 1.00 $100.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 17.97 $898.34 $50.00
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Subtotal (Total Children Is Unduplicated) 187 308 3329.76 $113293.33 $34.02
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Total 618 3784.36 $142847.21 $37.75
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Number of Children (Unduplicated) With at Least One Authorization 236