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: 01/01/09 and 03/31/09 Date of Report: 05-18-09 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 1.00 $37.00 $37.00
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Subtotal (Total Children Is Unduplicated) 1 1 1.00 $37.00 $37.00
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 6 6 5.40 $324.00 $60.00
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.08 $9.30 $119.60
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 2.57 $128.57 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.00 $111.00 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.00 $111.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 5.00 $375.00 $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 1 1 2.00 $111.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 5 9.00 $675.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.00 $242.50 $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 8 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 15 16 80.29 $3893.86 $48.50
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Subtotal (Total Children Is Unduplicated) 37 51 125.33 $6692.73 $53.40
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 3.50 $175.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.00 $50.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 64 67 125.01 $6250.51 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 32 32 45.48 $2274.17 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 39 55.55 $2777.50 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 39 42 70.25 $3512.30 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 3.00 $220.26 $73.42
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 4.57 $228.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 83 86 695.89 $34794.55 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.57 $128.57 $50.00
INTR -INTR INTERPRETER 1 1 2.00 $100.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 46 376.91 $25584.93 $67.88
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.29 $124.16 $54.32
PHY -97110 PT SESSION BY LICENSED PT 58 62 471.08 $31976.57 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 10.86 $589.76 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5264 EARMOLD 1 1 0.08 $1.46 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 9.02 $450.95 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 72 79 641.62 $43553.27 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 13.29 $175.37 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 9.57 $478.57 $50.00
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Subtotal (Total Children Is Unduplicated) 162 478 2546.03 $153484.95 $60.28
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Total 530 2672.37 $160214.68 $59.95
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Number of Children (Unduplicated) With at Least One Authorization 181