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: 04/01/09 and 06/30/09 Date of Report: 08-25-09 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 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 6.62 $397.34 $60.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 4 4 3.71 $185.72 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.00 $1500.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.00 $450.00 $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 12 12 24.00 $1800.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 17 17 16.43 $796.79 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.50 $75.00 $50.00
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Subtotal (Total Children Is Unduplicated) 47 75 98.27 $6176.41 $62.85
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 3.14 $216.42 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 19.57 $978.57 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 70 76 120.09 $6004.35 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.50 $37.50 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 45 75.17 $3758.29 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 47 66.16 $3308.06 $50.00
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.50 $37.50 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 59 63 88.42 $4420.84 $50.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 10.86 $797.13 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 133.00 $3325.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 71.43 $3571.43 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 3.57 $89.29 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 85 697.61 $34880.38 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 24.02 $1201.04 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 61 66 422.00 $28645.05 $67.88
PHY -97110 PT SESSION BY LICENSED PT 66 71 509.62 $34592.78 $67.88
PHY -97110HM PT SESSION BY PT ASST 2 2 38.29 $2079.68 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SENS -V5264 EARMOLD 4 4 3.13 $58.66 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 2.71 $135.72 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 103 798.57 $54206.91 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.21 $42.43 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 4 23.71 $1185.72 $50.00
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Subtotal (Total Children Is Unduplicated) 172 590 3118.27 $183573.70 $58.87
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Total 665 3216.54 $189750.11 $58.99
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Number of Children (Unduplicated) With at Least One Authorization 191