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: 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 4.14 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 1 1 4.14 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 13 14.00 $679.00 $48.50
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 46 46 47.00 $2350.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.00 $50.00 $50.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 172 187 199.14 $9658.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 103 116 163.14 $7912.43 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 193 212 220.86 $10711.57 $48.50
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Subtotal (Total Children Is Unduplicated) 369 577 648.14 $31647.43 $48.83
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 14.00 $700.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 137 142 279.20 $13960.01 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 51 97.60 $4880.22 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 29 59.79 $2989.28 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 89 92 152.10 $7605.01 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 52 58 378.21 $9455.35 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 412 438 2913.03 $145651.46 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 251 275 1305.74 $88633.80 $67.88
PHY -97110 PT SESSION BY LICENSED PT 182 202 1049.56 $71244.34 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 29 21.17 $21.17 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 2 2 2.36 $44.10 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 14 35.44 $1771.91 $50.00
SIC -SIC SPECIAL INSTRUCTION CONSULTATION 1 1 11.86 $592.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 275 307 1373.13 $93208.28 $67.88
TRAN -TRAN FAMILY TRANSPORTATION 5 5 29.00 $2900.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 389 454 2096.71 $1048.35 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 27.40 $1370.24 $50.00
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Subtotal (Total Children Is Unduplicated) 656 2120 9851.31 $448149.77 $45.49
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Total 2698 10503.59 $479797.19 $45.68
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Number of Children (Unduplicated) With at Least One Authorization 675