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: 10/01/09 and 12/31/09 Date of Report: 02-15-10 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 2 2 0.56 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 0.56 $0.00 $0.00
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
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 48 48 48.00 $2328.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 50 52 52.00 $2522.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 133 138 138.00 $6693.00 $48.50
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Subtotal (Total Children Is Unduplicated) 178 254 254.00 $12822.60 $50.48
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 4 3.92 $196.11 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 187 192 321.54 $16076.80 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 8 9 11.88 $297.08 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.40 $20.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.57 $28.34 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 182 187 303.31 $15165.50 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 5 6 7.48 $187.08 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 60.00 $4405.20 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 8.71 $217.86 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 13.00 $325.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 201 208 1340.43 $67021.66 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.57 $128.57 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 48 49 234.07 $15888.75 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 14.57 $791.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 60 60 228.50 $15510.59 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 5.71 $310.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 1.31 $1.31 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 6 6 37.07 $1853.57 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 139 146 561.91 $38142.40 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 11.07 $146.14 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 224 276 2555.08 $1277.54 $0.50
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Subtotal (Total Children Is Unduplicated) 291 1164 5723.12 $177991.41 $31.10
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Total 1420 5977.68 $190814.01 $31.92
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Number of Children (Unduplicated) With at Least One Authorization 298