Summary Report for FSPSAs Initiated During the Report Period Center: 54
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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.64 $208.79 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 5.64 $208.79 $37.00
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Subtotal (Total Children Is Unduplicated) 2 3 12.29 $417.57 $33.99
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 76 78 76.11 $4566.76 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.00 $140.40 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 34 34 44.14 $5279.49 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.00 $75.00 $75.00
NURS -NURS NURSING ASSESSMENT 4 4 14.00 $700.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 11 11.14 $540.43 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 54 58 66.57 $3228.71 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 14 15 15.14 $734.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 26 26.00 $1261.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 125 130 179.86 $8723.07 $48.50
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Subtotal (Total Children Is Unduplicated) 256 364 440.97 $25604.80 $58.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 12 12 18.67 $933.50 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 5.93 $296.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.87 $46.67 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 84 86 118.04 $5901.78 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 7 7 9.02 $225.42 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 48 68.80 $3440.24 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.43 $60.83 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 21 22.47 $1123.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.02 $0.56 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 81 85 127.32 $6366.07 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.25 $56.25 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 74.29 $928.57 $12.50
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 199 216 1631.47 $81573.35 $50.00
INTR -INTR INTERPRETER 11 11 121.14 $6057.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 100 106 710.13 $48203.53 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 53.79 $2921.89 $54.32
PHY -97110 PT SESSION BY LICENSED PT 82 90 463.52 $31463.97 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 15.39 $836.14 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 18.50 $18.50 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 6 6 4.68 $87.57 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 8.73 $436.43 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 189 206 1315.31 $89283.55 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.00 $54.32 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 12 12 57.64 $760.89 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 357 499 90594.65 $45297.32 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 28.43 $1421.43 $50.00
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Subtotal (Total Children Is Unduplicated) 489 1460 95480.49 $331295.87 $3.47
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Total 1827 95933.74 $357318.25 $3.72
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Number of Children (Unduplicated) With at Least One Authorization 531