Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 07/01/08 and 09/30/08 Date of Report: 11-18-08 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
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 6.10 $225.70 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 6.10 $225.70 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 6.18 $370.67 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 3 3 3.00 $150.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 5.00 $375.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 7.00 $525.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.00 $150.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 6 9.00 $499.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 9.00 $675.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 22.14 $1073.93 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 2.00 $97.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.00 $242.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 32.29 $1565.86 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 7 7 7.00 $350.00 $50.00
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Subtotal (Total Children Is Unduplicated) 49 72 110.61 $6110.53 $55.25
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 5.00 $250.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 48 54 169.18 $8459.17 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 24 34.25 $1712.50 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 23 39.43 $1971.43 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.00 $75.00 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 28 37.08 $1853.89 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 7.57 $555.89 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 87.00 $2175.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 90.00 $4500.00 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 19.29 $482.14 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 87 680.67 $34033.32 $50.00
INTR -INTR INTERPRETER 1 1 4.00 $200.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 49 52 422.13 $28653.92 $67.88
OCCT -97530HM OT SESSION BY OT ASST 6 6 33.36 $1812.21 $54.32
PHY -97110 PT SESSION BY LICENSED PT 52 57 489.81 $33248.42 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 31.21 $1695.56 $54.32
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 3.79 $189.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 97 760.28 $51608.02 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.71 $62.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 31 47 17681.64 $8840.82 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 1 1 2.50 $125.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 4.43 $221.67 $50.00
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Subtotal (Total Children Is Unduplicated) 166 495 20610.34 $182725.47 $8.87
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Total 570 20727.04 $189061.69 $9.12
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Number of Children (Unduplicated) With at Least One Authorization 187