Summary Report for FSPSAs Ending During the Report Period Center: 57
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 37 38 20.86 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 38 46 33.00 $1221.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.11 $114.91 $37.00
TCON -TCON TRANSITION CONFERENCE 4 4 4.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 70 91 60.96 $1335.91 $21.91
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.32 $15.68 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.00 $144.28 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 73 75 169.08 $10144.66 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 20 22 23.02 $2753.46 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 6 6 13.29 $1660.71 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 28 30 52.84 $6604.46 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 26 26 26.00 $780.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.06 $4.58 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.27 $20.42 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 6.50 $360.75 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 18 20.00 $1500.00 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 93 111 162.86 $7898.65 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 112 131 153.87 $7462.59 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 26 26 26.00 $1300.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 379 460 629.93 $30551.39 $48.50
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Subtotal (Total Children Is Unduplicated) 602 924 1294.03 $71748.63 $55.45
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 14.00 $700.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 40.55 $2027.62 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 18.20 $455.00 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 460 539 2605.16 $130258.23 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 157 169 761.47 $19036.68 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 91.46 $4573.10 $50.00
CONOP -CONOP CONSULT, OT, PHONE 6 7 25.90 $647.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 19 93.60 $4680.00 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 4 14.07 $351.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 617 777 3602.50 $180124.99 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 176 205 856.90 $21422.52 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 35 38 380.44 $27931.60 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 3 3 746.71 $9333.93 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 6.86 $171.43 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 25 453.00 $11325.01 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 30.14 $1507.14 $50.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 156 162 1111.86 $55592.85 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 34.29 $857.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 901 1224 21786.46 $1089322.97 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 125 160 1533.76 $104111.79 $67.88
OCCT -97530HM OT SESSION BY OT ASST 66 71 745.38 $40489.10 $54.32
PHY -97110 PT SESSION BY LICENSED PT 199 237 2492.73 $169206.48 $67.88
PHY -97110HM PT SESSION BY PT ASST 67 68 916.50 $49784.28 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 2.00 $1000.00 $500.00
SHIN -T1024HN *INITIAL SHINE SERVICES, INDIVIDUAL 1 1 11.43 $571.43 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 18 24 447.60 $22380.01 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 387 492 3978.17 $270038.22 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 81.29 $4415.44 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 126 141 1478.00 $19509.57 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 3 3 62.57 $6257.15 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 993 1820 27298.26 $13649.12 $0.50
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Subtotal (Total Children Is Unduplicated) 1280 6244 71722.25 $2261732.92 $31.53
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Total 7259 73077.24 $2334817.45 $31.95
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Number of Children (Unduplicated) With at Least One Authorization 1339