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: 10/01/08 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 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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
EXIT -EXIT TRANSITION ASSESSMENT 13 13 24.00 $1200.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 61 62 98.14 $7360.72 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 34 34 49.50 $3712.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 29 29 40.00 $3000.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 82 82 123.18 $6836.28 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 12 18.00 $1350.00 $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 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 8 8 8.00 $388.00 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 126 257 377.82 $24687.88 $65.34
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.00 $6000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.00 $150.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.50 $25.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 15 16 19.79 $989.64 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 2.07 $51.78 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 3.57 $178.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 19.72 $492.98 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 2 0.75 $37.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.33 $33.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 20.64 $1031.91 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.76 $193.93 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 2 2 390.00 $4875.00 $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 65 65 466.46 $23323.11 $50.00
INTR -INTR INTERPRETER 3 3 9.43 $471.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 25 27 176.36 $11971.45 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 30.29 $1645.12 $54.32
PHY -97110 PT SESSION BY LICENSED PT 25 25 171.90 $11668.34 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 11.00 $597.52 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 9.00 $9.00 $1.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 53 53 407.73 $27676.97 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 90.43 $1193.66 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 14.14 $707.15 $50.00
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Subtotal (Total Children Is Unduplicated) 157 256 1993.44 $96662.43 $48.49
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Total 514 2372.26 $121350.31 $51.15
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Number of Children (Unduplicated) With at Least One Authorization 203