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: 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 4 4 4.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 85.14 $3150.29 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 7.93 $293.36 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9 11 97.07 $3443.65 $35.48
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.00 $48.50 $48.50
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 5 5.00 $271.90 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 251 286 335.53 $20131.72 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 6.73 $315.12 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 103 110 138.56 $16571.81 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 7 7 7.00 $875.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 21 22 37.43 $4678.58 $125.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $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
NURS -NURS NURSING ASSESSMENT 4 4 2.80 $140.00 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 46 48 64.08 $3107.70 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 243 271 289.50 $14040.52 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 32 33 47.62 $2309.52 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 119 125 170.14 $8251.93 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 433 489 510.14 $24741.93 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.00 $100.00 $100.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 775 1417 1624.53 $96089.72 $59.15
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 40 43 172.42 $8621.12 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 27 109.21 $5460.49 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 9 10 29.83 $745.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 276 350 1293.07 $64653.70 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 34 36 113.52 $2838.07 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 169 228 628.67 $31433.41 $50.00
CONOP -CONOP CONSULT, OT, PHONE 22 23 73.77 $1844.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 70 225.25 $11262.43 $50.00
CONPP -CONPP CONSULT, PT, PHONE 13 15 61.93 $1548.21 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 267 339 1011.23 $50561.64 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 31 33 103.73 $2593.28 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 9.36 $687.00 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 37.14 $1857.14 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 1.14 $57.15 $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 615 897 14686.31 $734315.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 7 59.76 $2987.86 $50.00
INTR -INTR INTERPRETER 34 54 573.86 $28693.21 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 393 606 9789.11 $664485.10 $67.88
OCCT -97530HM OT SESSION BY OT ASST 52 62 889.42 $48313.30 $54.32
PHY -97110 PT SESSION BY LICENSED PT 221 348 4647.04 $315441.16 $67.88
PHY -97110HM PT SESSION BY PT ASST 25 27 444.37 $24138.25 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 22 23 23.00 $23.00 $1.00
SENS -FM FM RECEIVER HEARING AID 4 4 4.00 $6600.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 10.00 $5000.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.00 $65.00 $65.00
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 2.00 $228.00 $114.00
SENS -V5264 EARMOLD 17 18 67.04 $1255.07 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 15 100.20 $5010.25 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 536 788 11236.13 $762708.74 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 35.00 $1901.20 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 66 71 909.98 $12011.75 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 896 1817 481304.14 $240652.06 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 9 176.14 $8807.14 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1210 5942 528851.80 $3050474.99 $5.77
-----------------------------------------------------------------------------------------------------------------------------
Total 7370 530573.40 $3150008.35 $5.94
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1249