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: 10/01/08 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 2 2 2.00 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.43 $52.86 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 4.29 $158.57 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 4 4 7.71 $211.43 $27.41
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.00 $54.38 $54.38
AUDE -AUDE UNSPECIFIED AUDE SERVICES 78 81 75.62 $4537.33 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.00 $46.80 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 24 24 36.00 $4305.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 7.00 $875.00 $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
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 2 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 17 17 16.07 $779.46 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 61 65 65.00 $3152.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 6.00 $291.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 34 41.57 $2016.21 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 131 135 136.00 $6596.00 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 261 379 393.27 $23259.79 $59.15
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 13 13 19.00 $950.08 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 14.63 $731.67 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 4.90 $122.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 75 80 139.06 $6952.81 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 11 11 14.02 $350.60 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 59 64 73.41 $3670.31 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.60 $140.00 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 13.77 $688.27 $50.00
CONPP -CONPP CONSULT, PT, PHONE 7 7 10.57 $264.35 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 83 92 115.50 $5775.13 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 12 13 22.76 $568.99 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 15.00 $750.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 204 232 1552.45 $77622.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 2.53 $126.67 $50.00
INTR -INTR INTERPRETER 18 20 87.66 $4382.86 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 163 183 1254.47 $85153.10 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 93.14 $5059.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 72 80 437.25 $29680.83 $67.88
PHY -97110HM PT SESSION BY PT ASST 10 10 34.31 $1863.57 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 3.00 $3.00 $1.00
SENS -V5264 EARMOLD 5 5 8.00 $149.76 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 6.50 $325.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 194 211 1411.90 $95839.77 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 22 22 111.75 $1475.10 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 325 481 63309.35 $31654.67 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 34.00 $1700.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 464 1583 68794.54 $356001.18 $5.17
-----------------------------------------------------------------------------------------------------------------------------
Total 1966 69195.52 $379472.40 $5.48
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 530