Summary Report for FSPSAs Ending During the Report Period Center: 57
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 15 15 3.72 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 19 23 15.00 $555.00 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 32 39 19.72 $555.00 $28.15
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.02 $0.93 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 25 25 24.19 $1451.66 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 6.00 $717.60 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 11 11 10.14 $1267.36 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 20 20 20.00 $600.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.06 $4.58 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.27 $20.42 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.50 $138.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 10.50 $787.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 26 31.18 $1512.28 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 36 35.25 $1709.73 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 14 14 14.00 $700.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 135 145 145.35 $7049.70 $48.50
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Subtotal (Total Children Is Unduplicated) 222 296 299.47 $15960.51 $53.30
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 168 180 315.40 $15770.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 70 71 113.10 $2827.62 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 4.03 $201.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.47 $36.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 22.77 $1138.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 211 228 360.36 $18017.87 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 49 52 75.40 $1884.99 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 12 28.01 $2056.82 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 292.00 $3650.00 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 17 117.86 $2946.42 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.86 $42.86 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 10.00 $250.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 347 378 2496.78 $124839.23 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 25 26 94.86 $6438.90 $67.88
OCCT -97530HM OT SESSION BY OT ASST 37 39 160.79 $8733.86 $54.32
PHY -97110 PT SESSION BY LICENSED PT 55 57 259.86 $17639.09 $67.88
PHY -97110HM PT SESSION BY PT ASST 28 29 116.07 $6305.00 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 7 18.12 $905.96 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 96 396.29 $26899.88 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 10.14 $550.96 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 60 66 190.24 $2511.11 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 23.71 $2371.43 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 355 543 3075.80 $1537.90 $0.50
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Subtotal (Total Children Is Unduplicated) 470 1829 8189.41 $248694.07 $30.37
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Total 2164 8508.60 $265209.58 $31.17
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Number of Children (Unduplicated) With at Least One Authorization 508