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: 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 2 2 2.00 $120.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.90 $42.12 $46.80
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 3.00 $375.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 5 5 9.40 $470.00 $50.00
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.00 $1500.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.00 $300.00 $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 7 7 7.00 $339.50 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 13 13 24.57 $1191.71 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 2 2 3.50 $175.00 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 47 69 112.37 $7046.90 $62.71
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 3.14 $216.42 $68.86
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 9.00 $619.74 $68.86
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.50 $75.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 73 77 137.06 $6852.78 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 48.70 $2435.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 48 79.75 $3987.58 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 68 95.99 $4799.45 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.50 $37.50 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 3.00 $220.26 $73.42
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 99.00 $2475.00 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 12.00 $600.00 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 90 93 688.31 $34415.48 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 3 9.14 $457.15 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 45 45 342.23 $23230.45 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 19.00 $1032.08 $54.32
PHY -97110 PT SESSION BY LICENSED PT 61 62 507.37 $34440.51 $67.88
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.00 $1.00 $1.00
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 5.40 $270.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 3.00 $150.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 84 88 645.79 $43836.01 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 24.43 $322.46 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 25.57 $1278.57 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 168 543 2761.88 $161752.43 $58.57
-----------------------------------------------------------------------------------------------------------------------------
Total 612 2874.25 $168799.33 $58.73
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 180