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
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 21 22 5.29 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 13 9.00 $333.00 $37.00
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Subtotal (Total Children Is Unduplicated) 28 35 14.29 $333.00 $23.30
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 10.00 $360.70 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.00 $598.00 $119.60
BEHV -90801 PSYCHIATRIC DIAG INTERVIEW 1 1 2.00 $250.00 $125.00
BEHV -BEHV BEHAVIORAL ASSESSMENT 9 9 8.80 $1100.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 10.00 $1250.00 $125.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 9 9 9.00 $270.00 $30.00
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 5.50 $412.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 51 53 53.00 $2570.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 65 69 69.00 $3346.50 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 7 7 7.00 $350.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 225 239 249.39 $12095.63 $48.50
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Subtotal (Total Children Is Unduplicated) 300 418 429.69 $22663.83 $52.74
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 14 14 14.00 $700.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 310 332 478.03 $23901.64 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 29 32 48.63 $1215.84 $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 302 322 461.37 $23068.32 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 25 26 44.57 $1114.17 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 15 104.64 $7682.51 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 17.71 $442.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.14 $53.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 353 383 2329.73 $116486.70 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 65 69 282.71 $19190.64 $67.88
PHY -97110 PT SESSION BY LICENSED PT 75 80 274.00 $18599.11 $67.88
PHY -97110HM PT SESSION BY PT ASST 5 5 23.21 $1261.00 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 7 7 37.36 $1867.86 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 237 262 979.50 $66488.14 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 34.93 $461.06 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.27 $26.67 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 378 490 7382.94 $3691.47 $0.50
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Subtotal (Total Children Is Unduplicated) 491 2057 12522.93 $286561.99 $22.88
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Total 2510 12966.92 $309558.82 $23.87
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Number of Children (Unduplicated) With at Least One Authorization 512