Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 07/01/09 and 09/30/09 Date of Report: 11-16-09 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 7.00 $339.50 $48.50
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.02 $61.33 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 67 67 71.22 $8517.80 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 37.29 $1808.36 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 10.36 $502.32 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 31 32 32.00 $1552.00 $48.50
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Subtotal (Total Children Is Unduplicated) 114 138 160.88 $13031.31 $81.00
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 14 14.00 $21000.00 $1500.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.83 $20.83 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 7 7 11.01 $550.72 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 6.73 $168.34 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 4.13 $206.67 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.90 $22.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 7.99 $399.45 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 6.80 $170.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 13.63 $681.67 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.07 $51.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 48 48 93.02 $2325.48 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 206 1094.61 $54730.60 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 0.57 $28.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1 1 12.71 $863.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 8 8 68.00 $3693.77 $54.32
PHY -97110 PT SESSION BY LICENSED PT 2 2 50.43 $3423.09 $67.88
PHY -97110HM PT SESSION BY PT ASST 6 7 44.47 $2415.43 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 17 17 20.19 $20.19 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 10.06 $503.10 $50.00
SPL -92508 GROUP SPL SESSION PER CHILD 13 15 127.43 $1682.06 $13.20
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Subtotal (Total Children Is Unduplicated) 243 354 1589.59 $92956.92 $58.48
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Total 492 1750.47 $105988.23 $60.55
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Number of Children (Unduplicated) With at Least One Authorization 309