Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 04/01/10 and 06/30/10 Date of Report: 08-17-10 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 4 4 4.00 $0.00 $0.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 6 7 7.00 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.00 $478.40 $119.60
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 5.00 $250.00 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 39 39 77.00 $3850.00 $50.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.50 $487.50 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 82 82 144.79 $10858.93 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 50 52 95.50 $7162.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 13 13 19.00 $1425.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 79 79 138.35 $7678.56 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 25 28 54.00 $4050.00 $75.00
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 6.57 $318.71 $48.50
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Subtotal (Total Children Is Unduplicated) 180 319 565.21 $37446.35 $66.25
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 13 17.00 $25500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 24 26.00 $1300.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.77 $19.17 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 18 19 14.02 $700.83 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.00 $25.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 23 24.87 $1243.34 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.00 $75.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 15.25 $762.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.00 $25.00 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 235.71 $2946.43 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 172.86 $4321.43 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 118 125 698.31 $34915.48 $50.00
INTR -INTR INTERPRETER 12 19 27.00 $1350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 38 39 259.37 $17606.13 $67.88
OCCT -97530HM OT SESSION BY OT ASST 4 4 20.86 $1132.96 $54.32
PHY -97110 PT SESSION BY LICENSED PT 28 30 202.04 $13714.36 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 11.29 $613.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 7 7 7.00 $7.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 2 2 2.80 $52.42 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 57 385.90 $26194.57 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.71 $88.63 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 7.29 $364.29 $50.00
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Subtotal (Total Children Is Unduplicated) 223 393 2146.03 $135057.56 $62.93
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Total 719 2718.24 $172503.91 $63.46
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Number of Children (Unduplicated) With at Least One Authorization 289