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: 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 23 23 6.77 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 21 23 18.00 $666.00 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.12 $41.32 $37.00
TCON -TCON TRANSITION CONFERENCE 3 3 3.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 44 51 28.88 $707.32 $24.49
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.00 $144.28 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 17 17 15.09 $905.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 10 9.04 $1081.71 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.00 $250.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 21.62 $2701.98 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 1.00 $50.00 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 6 6 6.00 $180.00 $30.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 4.00 $222.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 8.50 $637.50 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 40 43 45.34 $2199.05 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 42 42 40.10 $1944.85 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 12 12 12.00 $600.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 152 160 180.07 $8733.27 $48.50
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Subtotal (Total Children Is Unduplicated) 242 323 352.76 $20098.47 $56.98
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 11.00 $550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 245 259 441.28 $22064.17 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 33 36 44.87 $1121.66 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 16.72 $835.96 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.23 $5.83 $25.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.73 $43.33 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 266 287 412.86 $20643.04 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 20 21 28.43 $710.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 43.17 $3169.59 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 1.00 $12.50 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 45.14 $1128.57 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 9.14 $457.15 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 17.14 $428.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 344 370 2265.72 $113285.77 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 37 39 155.14 $10531.10 $67.88
OCCT -97530HM OT SESSION BY OT ASST 21 22 96.40 $5236.19 $54.32
PHY -97110 PT SESSION BY LICENSED PT 54 54 229.21 $15558.76 $67.88
PHY -97110HM PT SESSION BY PT ASST 30 30 158.79 $8625.24 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 118.90 $5945.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 80 310.46 $21073.81 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 14.71 $799.28 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 46 46 208.21 $2748.43 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 373 549 2761.10 $1380.54 $0.50
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Subtotal (Total Children Is Unduplicated) 471 1843 7392.36 $236356.32 $31.97
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Total 2217 7774.00 $257162.11 $33.08
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Number of Children (Unduplicated) With at Least One Authorization 514