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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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 2 2 2.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 2.00 $74.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 3.14 $116.29 $37.00
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Subtotal (Total Children Is Unduplicated) 3 5 7.14 $190.29 $26.64
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 3 3.00 $163.14 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 64 64 64.04 $3842.47 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 23 24 31.57 $3775.94 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 9 9.00 $1125.00 $125.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.00 $75.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.00 $55.50 $55.50
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 2 2.00 $100.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 14 14.87 $721.04 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 56 56.00 $2716.00 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 27 31.00 $1503.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 106 109 114.71 $5563.64 $48.50
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Subtotal (Total Children Is Unduplicated) 222 322 340.19 $20372.83 $59.89
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 14.71 $735.71 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 7.57 $378.33 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 84 90 147.70 $7385.13 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 7.82 $195.54 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 57 77.16 $3858.09 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.07 $76.67 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 18 20.57 $1028.33 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 10.45 $261.37 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 80 106.13 $5306.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 6 12.67 $316.79 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.14 $207.15 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 198 217 1533.09 $76654.60 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 4.67 $233.33 $50.00
INTR -INTR INTERPRETER 20 23 144.24 $7211.79 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 108 120 912.90 $61967.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 59.39 $3226.23 $54.32
PHY -97110 PT SESSION BY LICENSED PT 64 72 376.61 $25564.42 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 22.68 $1231.90 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 4.00 $2000.00 $500.00
SENS -V5264 EARMOLD 1 1 0.27 $4.99 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 8.27 $413.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 164 180 1065.97 $72358.27 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 116.07 $1532.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 306 426 43564.07 $21782.04 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 30.71 $1535.72 $50.00
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Subtotal (Total Children Is Unduplicated) 442 1359 48257.95 $295469.34 $6.12
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Total 1686 48605.28 $316032.45 $6.50
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Number of Children (Unduplicated) With at Least One Authorization 475