Summary Report for FSPSAs Ending During the Report Period Center: 55
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
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 4.14 $517.86 $125.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 16 16 14.79 $717.26 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 19.00 $921.50 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 10.00 $485.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 8 8.00 $388.00 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 45 49 58.02 $2814.04 $48.50
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 7.14 $714.29 $100.00
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Subtotal (Total Children Is Unduplicated) 72 106 125.10 $6818.96 $54.51
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.00 $1500.00 $1500.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.00 $150.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.51 $25.42 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.00 $100.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 20.86 $1042.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 26 159.72 $7985.96 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 4.29 $214.29 $50.00
INTR -INTR INTERPRETER 3 3 12.43 $621.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 59 63 327.50 $22230.82 $67.88
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.00 $1195.04 $54.32
PHY -97110 PT SESSION BY LICENSED PT 31 33 192.68 $13079.18 $67.88
PHY -97110HM PT SESSION BY PT ASST 1 1 2.14 $116.40 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 1 1 1.33 $1.33 $1.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 2.29 $114.29 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 101 501.89 $34068.52 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 39.43 $520.46 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 79 105 1042.66 $521.33 $0.50
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Subtotal (Total Children Is Unduplicated) 153 352 2335.73 $83487.31 $35.74
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Total 458 2460.82 $90306.27 $36.70
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Number of Children (Unduplicated) With at Least One Authorization 172