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: 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.10 $3.70 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 0.10 $3.70 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 1.67 $100.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 2.79 $139.29 $50.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 9 9 15.00 $1125.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.00 $300.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 9.00 $675.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.00 $166.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 16 30.00 $2250.00 $75.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.00 $242.50 $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 18 19 29.29 $1420.36 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 2.00 $100.00 $50.00
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Subtotal (Total Children Is Unduplicated) 49 79 117.74 $7438.14 $63.18
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 4.77 $238.34 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 49 51 77.55 $3877.50 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 40 77.86 $3892.88 $50.00
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.77 $19.17 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 35 78.58 $3929.21 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.12 $77.92 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 40 43 63.45 $3172.47 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.00 $73.42 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 110.00 $2750.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 70 72 476.59 $23829.31 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 1.17 $58.34 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 64 71 564.57 $38323.15 $67.88
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.43 $783.76 $54.32
PHY -97110 PT SESSION BY LICENSED PT 56 59 480.14 $32591.63 $67.88
PHY -97110HM PT SESSION BY PT ASST 4 4 33.70 $1830.84 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.79 $89.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 72 76 524.58 $35608.59 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 34.71 $458.23 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 5 6 604.29 $302.14 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
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Subtotal (Total Children Is Unduplicated) 150 474 3155.05 $151957.16 $48.16
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Total 554 3272.89 $159399.01 $48.70
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Number of Children (Unduplicated) With at Least One Authorization 178