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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 3 3 3.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
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
EVAL -EVAL DEVELOPMENTAL EVALUATION 23 23 23.00 $1150.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 39 41 47.00 $2350.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.00 $300.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.50 $187.50 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.50 $360.75 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 243 246 417.43 $31307.15 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 175 181 259.43 $19457.15 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 106 106 138.03 $10352.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 335 349 519.00 $28804.23 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 63 66 88.50 $6637.50 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 34.72 $1684.10 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 26 26.00 $1261.00 $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 16 17 17.00 $824.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 46 50 56.86 $2757.57 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 3 3 3.00 $300.00 $100.00
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 527 1131 1650.97 $108218.11 $65.55
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 24 33.00 $49500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 11.33 $566.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 17 18.38 $918.89 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 4.27 $106.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 29 36 76.19 $3809.28 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 8 19.29 $482.14 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 39 114.51 $5725.47 $50.00
CONOP -CONOP CONSULT, OT, PHONE 10 12 28.00 $700.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 8 6.05 $302.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 4 7.75 $193.75 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 48 168.73 $8436.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 20 21 38.68 $967.08 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 15 16 7131.71 $89146.43 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 13.86 $346.43 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 43 43 306.53 $15326.43 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 184 3480.97 $174048.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 3 46.50 $2325.00 $50.00
INTR -INTR INTERPRETER 12 17 25.25 $1262.50 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 100 134 2010.94 $136502.55 $67.88
OCCT -97530HM OT SESSION BY OT ASST 39 44 678.03 $36830.43 $54.32
PHY -97110 PT SESSION BY LICENSED PT 58 88 1406.24 $95455.67 $67.88
PHY -97110HM PT SESSION BY PT ASST 39 47 598.23 $32496.01 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 7.00 $7.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 2 2 2.89 $54.11 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.50 $75.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 152 223 3979.32 $270116.53 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 25.93 $1408.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 75 93 1680.79 $22186.37 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 44.57 $4457.14 $100.00
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 15.21 $760.72 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 41.50 $2075.00 $50.00
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Subtotal (Total Children Is Unduplicated) 436 1144 22024.15 $957089.53 $43.46
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Total 2278 23678.12 $1065307.64 $44.99
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Number of Children (Unduplicated) With at Least One Authorization 710