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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 11 12 2.54 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 4.50 $166.50 $37.00
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Subtotal (Total Children Is Unduplicated) 14 19 7.04 $166.50 $23.64
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 6.00 $216.42 $36.07
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.00 $239.20 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 8 8 7.80 $975.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 7 7 7.00 $875.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 4 4 4.00 $120.00 $30.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 3.00 $225.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 19 19.00 $921.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 33 35 35.00 $1697.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 93 98 108.00 $5238.00 $48.50
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Subtotal (Total Children Is Unduplicated) 128 185 195.80 $10857.62 $55.45
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 160 174 244.23 $12211.42 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 17 20 29.40 $735.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.59 $179.45 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 2.60 $130.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 155 169 237.54 $11877.13 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 16 17 27.97 $699.17 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 69.29 $5087.30 $73.42
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.14 $53.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 202 1256.85 $62842.40 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 27 28 127.43 $8649.85 $67.88
PHY -97110 PT SESSION BY LICENSED PT 42 43 159.21 $10807.45 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 7.79 $422.92 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 8.36 $417.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 99 108 379.64 $25769.82 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 22.07 $291.34 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 194 262 2643.62 $1321.81 $0.50
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Subtotal (Total Children Is Unduplicated) 235 1055 5226.73 $141746.48 $27.12
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Total 1259 5429.57 $152770.60 $28.14
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Number of Children (Unduplicated) With at Least One Authorization 242