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: 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 18 18 6.69 $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) 31 49 31.19 $721.50 $23.13
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 28 28 28.00 $1680.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 10 10 9.07 $1133.34 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 72 73 74.87 $3631.04 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 66 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 279 288 294.05 $14261.27 $48.50
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Subtotal (Total Children Is Unduplicated) 370 508 515.98 $26886.72 $52.11
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 2.00 $100.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.23 $61.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 310 319 491.86 $24593.04 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 29 29 41.20 $1030.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 15.33 $766.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.13 $53.33 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.60 $280.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 285 291 445.68 $22283.85 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 36 37 49.75 $1243.81 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 14 128.07 $9402.66 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 4.14 $103.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 360 368 2230.60 $111529.79 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 61 63 239.21 $16237.86 $67.88
OCCT -97530HM OT SESSION BY OT ASST 5 5 58.00 $3150.56 $54.32
PHY -97110 PT SESSION BY LICENSED PT 66 67 306.00 $20771.27 $67.88
PHY -97110HM PT SESSION BY PT ASST 3 3 16.14 $876.88 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 20.49 $1024.52 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 273 291 1216.39 $82568.59 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 19 19 74.64 $985.29 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 2 2 12.70 $1270.47 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 385 459 9361.16 $4680.58 $0.50
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Subtotal (Total Children Is Unduplicated) 545 1989 14723.34 $303015.40 $20.58
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Total 2546 15270.51 $330623.62 $21.65
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Number of Children (Unduplicated) With at Least One Authorization 580