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: 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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 4.00 $240.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 21 21 21.00 $1050.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 44 46 57.00 $2850.00 $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 242 245 409.00 $30675.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 173 179 254.71 $19103.57 $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 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 28 28.00 $1358.00 $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 17 18 18.00 $873.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 48 51.57 $2501.21 $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) 515 1133 1614.81 $106148.82 $65.73
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 23 30.00 $45000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 14.33 $716.67 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 17 31.75 $1587.50 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 4.27 $106.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 33 41 71.53 $3576.43 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 16 17 30.32 $758.09 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 32 93.88 $4693.82 $50.00
CONOP -CONOP CONSULT, OT, PHONE 17 18 48.72 $1217.98 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 6 2.00 $100.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 6.38 $159.58 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 44 50 155.51 $7775.73 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 26 48.91 $1222.68 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 14 15 8076.14 $100951.78 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 133.57 $3339.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 255 4113.29 $205664.64 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 38.93 $1946.43 $50.00
INTR -INTR INTERPRETER 10 15 29.68 $1483.93 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 96 139 2072.66 $140692.01 $67.88
OCCT -97530HM OT SESSION BY OT ASST 37 42 746.64 $40557.32 $54.32
PHY -97110 PT SESSION BY LICENSED PT 70 99 1495.03 $101482.68 $67.88
PHY -97110HM PT SESSION BY PT ASST 25 34 473.02 $25694.37 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 20.00 $20.00 $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
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.50 $75.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 166 241 4312.31 $292719.60 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 35.93 $1951.64 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 55 63 1253.17 $16541.80 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 35.00 $3500.00 $100.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 107.10 $5354.77 $50.00
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Subtotal (Total Children Is Unduplicated) 466 1192 23483.56 $1009409.11 $42.98
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Total 2328 25101.38 $1115557.93 $44.44
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Number of Children (Unduplicated) With at Least One Authorization 627