Summary Report for FSPSAs Ending During the Report Period Center: 54
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: 01/01/08 and 12/31/08 Date of Report: 02-16-09 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 3 3 3.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 84.14 $3113.29 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.93 $293.36 $37.00
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Subtotal (Total Children Is Unduplicated) 8 9 95.07 $3406.65 $35.83
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 5 6 6.00 $326.28 $54.38
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 216 249 301.67 $18100.37 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.73 $174.72 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 98 106 128.56 $15375.81 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 7 7 7.00 $875.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 20 22 37.43 $4678.58 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.00 $75.00 $75.00
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
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.00 $75.00 $75.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 4 4.00 $200.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 45 47 59.14 $2868.43 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 248 273 290.21 $14075.17 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 27 27 40.29 $1953.86 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 109 116 159.71 $7746.14 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 405 454 477.00 $23134.50 $48.50
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Subtotal (Total Children Is Unduplicated) 715 1322 1521.75 $89880.47 $59.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.00 $7500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 4.03 $277.73 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 34 41 177.27 $8863.41 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 19 87.19 $4359.65 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 8 9 30.70 $767.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 197 255 1018.52 $50925.82 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 51 58 172.39 $4309.73 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 147 199 553.22 $27661.01 $50.00
CONOP -CONOP CONSULT, OT, PHONE 33 36 104.92 $2622.92 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 56 189.92 $9496.14 $50.00
CONPP -CONPP CONSULT, PT, PHONE 14 17 63.23 $1580.71 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 195 258 814.74 $40736.84 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 49 52 150.46 $3761.61 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.36 $687.00 $73.42
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 13.00 $325.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 33.14 $1657.14 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.14 $7.15 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 83 89 822.78 $41138.81 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.00 $475.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 458 656 12222.88 $611144.23 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 1 1 3.03 $151.67 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 6 36.42 $1821.19 $50.00
INTR -INTR INTERPRETER 24 42 483.04 $24152.13 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 394 610 10598.83 $719448.61 $67.88
OCCT -97530HM OT SESSION BY OT ASST 70 81 1365.42 $74169.88 $54.32
PHY -97110 PT SESSION BY LICENSED PT 226 346 5035.15 $341786.21 $67.88
PHY -97110HM PT SESSION BY PT ASST 44 49 728.72 $39584.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 3 3 6.00 $3000.00 $500.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 2 1.03 $245.02 $237.12
SENS -V5264 EARMOLD 14 18 73.57 $1377.17 $18.72
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.03 $201.67 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 11 91.60 $4580.25 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 474 725 10849.72 $736478.78 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 8 69.57 $3779.12 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 74 83 1343.14 $17729.49 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 717 1482 323194.77 $161597.38 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.29 $114.29 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 123.00 $6150.00 $50.00
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Subtotal (Total Children Is Unduplicated) 1071 5242 370508.25 $2958167.49 $7.98
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Total 6573 372125.07 $3051454.60 $8.20
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Number of Children (Unduplicated) With at Least One Authorization 1153