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: 01/01/10 and 03/31/10 Date of Report: 05-17-10 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 0.16 $0.00 $0.00
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Subtotal (Total Children Is Unduplicated) 2 2 0.16 $0.00 $0.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.00 $358.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 4 4 4.00 $500.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 40 42 42.00 $2037.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 53 54 54.00 $2619.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 147 154 155.00 $7517.50 $48.50
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Subtotal (Total Children Is Unduplicated) 185 267 268.00 $13697.30 $51.11
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 9.00 $450.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 212 220 418.08 $20904.01 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 12 12 12.74 $318.45 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 6.47 $323.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 6.44 $322.22 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 197 204 393.06 $19653.14 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 14 14 17.03 $425.83 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 74.00 $5433.08 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 32.29 $807.15 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 13.43 $335.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 231 242 1566.36 $78317.88 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 46 192.43 $13062.05 $67.88
OCCT -97530HM OT SESSION BY OT ASST 10 10 39.71 $2157.28 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 53 230.32 $15634.22 $67.88
PHY -97110HM PT SESSION BY PT ASST 8 8 33.00 $1792.56 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 1.63 $1.63 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 34.20 $1710.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 172 751.79 $51031.23 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 75.71 $999.43 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 248 295 3313.79 $1656.90 $0.50
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Subtotal (Total Children Is Unduplicated) 302 1328 7221.49 $215336.11 $29.82
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Total 1597 7489.65 $229033.41 $30.58
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Number of Children (Unduplicated) With at Least One Authorization 306