Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 19 19 6.81 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 21 23 18.00 $666.00 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 29 45 27.81 $666.00 $23.95
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 16 16 16.00 $577.12 $36.07
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 11.29 $1410.71 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 6 6 9.70 $1212.50 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 13 13 13.00 $1625.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 6 6 6.00 $180.00 $30.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 7.50 $562.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 36 38 38.00 $1843.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 59 66 66.00 $3201.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 12 12 12.00 $600.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 186 195 199.27 $9664.36 $48.50
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Subtotal (Total Children Is Unduplicated) 265 369 387.75 $21696.19 $55.95
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 18 18 18.00 $900.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 313 327 522.55 $26127.40 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 33 34 59.29 $1482.26 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.58 $178.89 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.50 $25.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 305 316 518.79 $25939.43 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 24 24 34.67 $866.66 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 45.44 $3336.07 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 33.86 $846.43 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.71 $492.86 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 361 378 2606.34 $130317.04 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 56 58 323.07 $21930.12 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 13.93 $756.60 $54.32
PHY -97110 PT SESSION BY LICENSED PT 65 68 345.07 $23423.47 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 43.86 $2382.33 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 53.43 $2671.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 217 234 911.71 $61886.65 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 35.50 $468.60 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.83 $283.33 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 389 464 18006.57 $9003.28 $0.50
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Subtotal (Total Children Is Unduplicated) 494 1969 23600.69 $313319.84 $13.28
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Total 2383 24016.24 $335682.03 $13.98
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Number of Children (Unduplicated) With at Least One Authorization 513