Summary Report for FSPSAs Ending During the Report Period Center: 04
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 2 2 2.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 2.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 53 80 106.86 $5182.57 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 8.00 $956.80 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 365 496 554.53 $27726.43 $50.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.50 $25.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 373 495 528.29 $25622.08 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 280 370 438.24 $21254.78 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 491 637 767.29 $37213.57 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 5 7 42.86 $2142.86 $50.00
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Subtotal (Total Children Is Unduplicated) 1074 2107 2459.57 $120847.24 $49.13
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 54 55 60.10 $3005.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 731 1203 5213.30 $260664.97 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 19 195.84 $4896.07 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 322 493 1964.50 $98224.82 $50.00
CONOP -CONOP CONSULT, OT, PHONE 4 4 48.04 $1200.95 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 176 288 1186.52 $59326.14 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 20.57 $514.29 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 468 720 2745.09 $137254.41 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 18 18 176.22 $4405.48 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 30.86 $2265.53 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 22 22 169.40 $4235.04 $25.00
EIGF -T1027TTHM EI GROUP SESSION BY PARAPROF 2 2 15.00 $187.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 314 506 3663.08 $91576.96 $25.00
EIIF -90846 FAMILY PSYCHOTHERAPY W/O PATIENT 1 1 7.71 $385.72 $50.00
EIIF -90847 FAMILY PSYCHOTHERAPY WITH PATIENT 1 1 8.29 $414.29 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 189 197 1664.21 $83210.27 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 6 6 90.57 $2264.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1026 1826 33090.77 $1654538.71 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 496 889 6949.90 $471759.19 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 3 41.82 $2271.74 $54.32
PHY -97110 PT SESSION BY LICENSED PT 459 837 7327.16 $497367.82 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 23.57 $1280.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 29 49.51 $49.51 $1.00
SENS -V5264 EARMOLD 1 1 1.00 $18.72 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 3 3 11.18 $559.05 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 28 47 231.03 $11551.68 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 685 1128 8584.84 $582739.13 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.50 $151.80 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 8 8 60.32 $6031.91 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 970 1809 10573.05 $5286.52 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 2 2 2.80 $139.77 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 22 34 283.97 $14198.57 $50.00
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Subtotal (Total Children Is Unduplicated) 1585 10163 84502.22 $4002001.20 $47.36
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Total 12272 86963.79 $4122848.44 $47.41
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Number of Children (Unduplicated) With at Least One Authorization 1657