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
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 16 16 16.00 $960.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 7.00 $837.20 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 5 5 5.00 $625.00 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 83 86 86.00 $4171.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 91 93 93.00 $4510.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 315 332 334.00 $16199.00 $48.50
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Subtotal (Total Children Is Unduplicated) 381 540 542.00 $27427.70 $50.60
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 19 19 19.00 $950.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 357 371 702.99 $35149.27 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 19 19 23.88 $596.96 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 13.47 $673.34 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 7.88 $393.89 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 342 358 689.18 $34458.88 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 20 20 25.94 $648.51 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 94.00 $6901.48 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 40.14 $1003.57 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 5 5 31.00 $775.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 389 408 2712.43 $135621.45 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 80 81 349.36 $23714.36 $67.88
OCCT -97530HM OT SESSION BY OT ASST 21 21 89.57 $4865.52 $54.32
PHY -97110 PT SESSION BY LICENSED PT 86 87 408.68 $27741.10 $67.88
PHY -97110HM PT SESSION BY PT ASST 11 11 45.21 $2456.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 2.50 $2.50 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 5 5 34.20 $1710.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 345 365 1599.64 $108583.78 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.14 $170.72 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 24 24 120.64 $1592.49 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 414 490 5262.20 $2631.10 $0.50
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Subtotal (Total Children Is Unduplicated) 571 2314 12275.04 $390639.94 $31.82
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Total 2856 12817.21 $418067.64 $32.62
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Number of Children (Unduplicated) With at Least One Authorization 577