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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 Page: 1
Child has a MEDICAID # Filter: Y
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 7 7 1.98 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 5 2.50 $92.50 $37.00
TCON -TCON TRANSITION CONFERENCE 1 1 1.00 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 11 13 5.48 $92.50 $16.87
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 10 10 10.00 $600.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.00 $358.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 6 6 6.00 $750.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 3 3 3.00 $90.00 $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 1 1 1.00 $55.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.00 $150.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 12 11.25 $545.73 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 36 37 35.93 $1742.46 $48.50
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Subtotal (Total Children Is Unduplicated) 66 84 80.51 $4706.98 $58.46
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 67 74 122.04 $6101.91 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 29 30 48.54 $1213.57 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.30 $15.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 18.73 $936.67 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.00 $25.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 91 136.40 $6819.99 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 19 21 30.03 $750.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 17.05 $1251.78 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 292.00 $3650.00 $12.50
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 34.43 $860.71 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 147 165 1052.50 $52624.98 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 9 9 29.43 $1997.61 $67.88
OCCT -97530HM OT SESSION BY OT ASST 18 20 80.29 $4361.11 $54.32
PHY -97110 PT SESSION BY LICENSED PT 22 23 111.86 $7592.86 $67.88
PHY -97110HM PT SESSION BY PT ASST 15 15 60.00 $3259.20 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 6 17.65 $882.62 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 30 120.86 $8203.77 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 17 18 49.93 $659.06 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 146 224 1200.61 $600.30 $0.50
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Subtotal (Total Children Is Unduplicated) 189 753 3423.64 $101806.96 $29.74
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Total 850 3509.64 $106606.45 $30.38
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Number of Children (Unduplicated) With at Least One Authorization 198