Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 12 13.000000 $630.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 9.142857 $548.5700 $60.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 4.000000 $500.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 18 20 39.000000 $4875.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 115 117 233.250000 $11662.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 16 32.000000 $2400.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 135 135 270.500000 $20287.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 57 114.000000 $8550.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 135 135 270.000000 $14985.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 170 186 372.500000 $27937.5000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $48.5000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.000000 $242.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 7.000000 $339.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 418 726 1429.392857 $96859.5700 $67.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 14.714286 $22071.4500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.955556 $97.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 102 113 180.502380 $9025.1300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 6 6 3.000000 $75.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 30 33 80.471427 $4023.5700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 10 10 14.347619 $358.6900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 6.004762 $300.2400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 33.066666 $1653.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 14.180952 $354.5200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 26 79.942857 $3997.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 15.185714 $379.6400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 96.857142 $2421.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.714286 $585.7200 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 8.428571 $210.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 425 442 2583.104780 $129155.1600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 22.285714 $1114.2900 $50.0000
INTR -INTR INTERPRETER 58 97 302.007141 $15100.3500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 53.857143 $3655.8200 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 55 59 492.285716 $33416.3600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.285714 $613.0400 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 27 27 26.733333 $26.7300 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.955556 $62.1100 $65.0000
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 26.714286 $1335.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 75 532.080954 $36117.6200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.857143 $156.5100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 564 814 4102.914308 $2051.4600 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 10.714286 $535.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 619 1782 8738.168292 $268913.2300 $30.7700
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Total 2508 10167.561149 $365772.8100 $35.9700
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Number of Children (Unduplicated) With at Least One Authorization 717