Summary Report for FSPSAs Initiated During the Report Period Center: 51
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 2 2 1.63 $98.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.96 $114.29 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.00 $250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 7.07 $353.57 $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 2 2 3.00 $225.00 $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 8 8 10.00 $750.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.00 $145.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 3 3 3.00 $145.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 7.00 $339.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 24.14 $1170.93 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 41 66 83.80 $5041.78 $60.16
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 12.58 $629.05 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 55 59 98.86 $4943.18 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 28 40.78 $2039.17 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.50 $37.50 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 35 47.78 $2389.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 40 51.62 $2580.88 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 2.14 $157.33 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 22.00 $1100.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 67 524.26 $26212.99 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.64 $132.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 40 40 228.59 $15516.70 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 26.93 $1462.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 49 52 353.19 $23974.25 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 54.43 $2956.56 $54.32
SENS -V5264 EARMOLD 1 1 0.96 $17.89 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 4.37 $218.34 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 63 69 531.23 $36059.80 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 10.86 $143.31 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1 1 454.29 $227.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 4 24.00 $1200.00 $50.00
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Subtotal (Total Children Is Unduplicated) 139 414 2494.50 $122035.66 $48.92
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Total 480 2578.30 $127077.44 $49.29
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Number of Children (Unduplicated) With at Least One Authorization 148