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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 6 6 0.37 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 13 9.00 $333.00 $37.00
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Subtotal (Total Children Is Unduplicated) 12 19 9.37 $333.00 $35.55
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 19 19 19.00 $1140.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 6 6 6.00 $750.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 9.00 $1125.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 9 9 9.00 $270.00 $30.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 5.50 $412.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 101 101 101.00 $4898.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 90 92 92.00 $4462.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 7 7 7.00 $350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 287 293 299.14 $14508.43 $48.50
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Subtotal (Total Children Is Unduplicated) 389 545 551.64 $28322.03 $51.34
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 11.17 $558.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 336 343 567.54 $28376.91 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 23 23 35.63 $890.83 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.70 $85.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 314 320 525.02 $26251.13 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 22 22 32.23 $805.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 17 17 244.00 $17914.48 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 16.14 $403.57 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 8.14 $203.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 365 371 2522.35 $126117.71 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 10.43 $521.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 87 88 356.71 $24213.77 $67.88
PHY -97110 PT SESSION BY LICENSED PT 91 95 411.43 $27927.83 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 4.57 $248.32 $54.32
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 1 1 0.02 $0.42 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 95.00 $4750.24 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 307 316 1278.84 $86807.53 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 12.57 $165.94 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 399 472 5068.69 $2534.34 $0.50
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Subtotal (Total Children Is Unduplicated) 564 2104 11203.20 $349277.17 $31.18
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Total 2668 11764.21 $377932.20 $32.13
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Number of Children (Unduplicated) With at Least One Authorization 593