Summary Report for FSPSAs Ending During the Report Period Center: 57
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: 01/01/09 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 13 13 5.57 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 23 26 19.50 $721.50 $37.00
TCON -TCON TRANSITION CONFERENCE 5 5 5.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 35 44 30.07 $721.50 $24.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 9.00 $324.63 $36.07
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 6.00 $717.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 2.17 $270.84 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 8 8 8.00 $1000.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 7 7 7.00 $210.00 $30.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 13 13 14.00 $1050.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 43 45 75.14 $3644.43 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 57 62 62.00 $3007.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 12 12 12.00 $600.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 174 196 196.29 $9519.86 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 2 2 6.84 $684.29 $100.00
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Subtotal (Total Children Is Unduplicated) 274 365 402.44 $21236.64 $52.77
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.00 $550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 287 331 524.74 $26236.94 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 27 28 44.80 $1120.12 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 5.33 $266.67 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 5.17 $258.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.53 $13.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 277 319 497.88 $24893.94 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 26 27 44.97 $1124.16 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 39.67 $2912.33 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 18.57 $464.29 $25.00
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.57 $128.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 31.29 $782.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 346 400 2700.84 $135042.12 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 35 35 165.00 $11200.22 $67.88
OCCT -97530HM OT SESSION BY OT ASST 11 11 37.00 $2009.84 $54.32
PHY -97110 PT SESSION BY LICENSED PT 42 45 219.43 $14894.80 $67.88
PHY -97110HM PT SESSION BY PT ASST 24 26 86.57 $4702.56 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 49.56 $2478.09 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 133 147 638.86 $43365.95 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 23 23 56.21 $742.03 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 371 504 5344.16 $2672.08 $0.50
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Subtotal (Total Children Is Unduplicated) 467 1939 10526.16 $278858.49 $26.49
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Total 2348 10958.66 $300816.63 $27.45
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Number of Children (Unduplicated) With at Least One Authorization 504