Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 10/01/08 and 12/31/08 Date of Report: 02-16-09 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
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.00 $60.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 32 48 81.50 $6112.50 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 21 16.56 $802.94 $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 31 31 17.82 $864.39 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 75 75 70.06 $3397.92 $48.50
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Subtotal (Total Children Is Unduplicated) 124 183 194.94 $11691.39 $59.97
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.00 $3000.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 3 1.33 $66.67 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 5 5 9.80 $489.77 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 10 15.28 $763.93 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 14.16 $708.10 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.38 $34.59 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 8.58 $429.16 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.77 $19.17 $25.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 4.43 $110.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 134 138 902.72 $45135.78 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 25.00 $1250.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 30 31 236.43 $16048.77 $67.88
OCCT -97530HM OT SESSION BY OT ASST 14 14 73.53 $3993.95 $54.32
PHY -97110 PT SESSION BY LICENSED PT 49 50 389.45 $26436.02 $67.88
PHY -97110HM PT SESSION BY PT ASST 12 12 66.29 $3600.64 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 15 16 21.86 $21.86 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 2 2 4.78 $89.44 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 95 695.84 $47233.65 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.71 $690.64 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 32 32 223.55 $2950.89 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 15.47 $773.45 $50.00
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Subtotal (Total Children Is Unduplicated) 295 438 2727.36 $155997.17 $57.20
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Total 621 2922.29 $167688.56 $57.38
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Number of Children (Unduplicated) With at Least One Authorization 311