Summary Report for FSPSAs Initiated During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 4 4 0.36 $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) 6 11 4.86 $166.50 $34.29
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 11.00 $660.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.00 $119.60 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $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 45 45 45.00 $2182.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 45 46 46.00 $2231.00 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 2 2 2.00 $100.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 114 118 118.00 $5723.00 $48.50
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Subtotal (Total Children Is Unduplicated) 164 237 237.00 $12236.10 $51.63
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 4.10 $205.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 183 188 298.70 $14935.24 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 12 19.05 $476.25 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 171 175 276.97 $13848.47 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 11 11 16.25 $406.25 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 63.14 $4635.94 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.29 $82.14 $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 202 207 1389.64 $69481.95 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 10.43 $521.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 43 44 161.21 $10943.24 $67.88
PHY -97110 PT SESSION BY LICENSED PT 51 51 239.00 $16223.36 $67.88
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 8 94.87 $4743.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 121 491.48 $33361.76 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.29 $82.97 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 224 272 3492.03 $1746.02 $0.50
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Subtotal (Total Children Is Unduplicated) 273 1106 6568.60 $171747.16 $26.15
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Total 1354 6810.46 $184149.76 $27.04
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Number of Children (Unduplicated) With at Least One Authorization 284