Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 2 2 5.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 5.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 46 69 96.86 $4697.57 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.00 $239.20 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 279 352 466.10 $23305.00 $50.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.50 $25.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 4 4 4.00 $200.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 459 634 713.18 $34589.05 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 312 446 526.89 $25553.96 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 577 791 1013.53 $49156.12 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 3 27.71 $1385.72 $50.00
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Subtotal (Total Children Is Unduplicated) 1137 2304 2853.76 $139282.98 $48.81
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 43 44 51.10 $2555.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 634 975 4351.59 $217579.28 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 268 412 1726.99 $86349.33 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 146 238 1097.63 $54881.38 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 422 589 2314.92 $115746.21 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 18.17 $454.17 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 16 16 37.51 $2754.18 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 307 493 3807.03 $95175.81 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 40.00 $1000.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1232 2068 31842.71 $1592135.59 $50.00
INTR -INTR INTERPRETER 1 1 0.50 $25.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 606 1021 8523.59 $578581.56 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 2 40.00 $2172.80 $54.32
PHY -97110 PT SESSION BY LICENSED PT 491 883 8596.14 $583505.79 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 23.57 $1280.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 49 62 85.37 $85.37 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 3 3 3.36 $62.82 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 34 52 292.89 $14644.30 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 11.86 $592.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 780 1239 9983.65 $677690.10 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.50 $151.80 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 8 8 49.89 $4989.04 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1076 1858 10262.11 $5131.05 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 22 38 330.49 $16524.52 $50.00
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Subtotal (Total Children Is Unduplicated) 1723 10012 83506.55 $4056068.33 $48.57
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Total 12318 86365.46 $4195351.30 $48.58
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Number of Children (Unduplicated) With at Least One Authorization 1777