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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 5 4.38 $262.66 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 4.79 $239.29 $50.00
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 4 4 8.00 $600.00 $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 14 15 29.00 $2175.00 $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 3 3 3.00 $145.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.00 $48.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.00 $194.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 34.14 $1655.93 $48.50
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Subtotal (Total Children Is Unduplicated) 36 59 111.31 $6960.87 $62.54
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 17.07 $853.58 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 26 46.84 $2342.23 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 23 34.16 $1707.88 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 31.90 $1595.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 38 49.96 $2498.20 $50.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 46.00 $1150.00 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 39 39 304.63 $15231.65 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.63 $31.67 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 33 34 323.04 $21927.66 $67.88
PHY -97110 PT SESSION BY LICENSED PT 36 37 367.52 $24947.18 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 0.57 $31.04 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 2 2 2.00 $2.00 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 4.79 $239.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 70 543.29 $36878.23 $67.88
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 24.14 $1207.15 $50.00
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Subtotal (Total Children Is Unduplicated) 116 303 1796.54 $110642.71 $61.59
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Total 362 1907.85 $117603.58 $61.64
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Number of Children (Unduplicated) With at Least One Authorization 132