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 8 8 9.000000 $436.5000 $48.5000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 112 114 227.250000 $11362.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 21 42.000000 $3150.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 145 169 330.250000 $18559.0000 $56.2000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 99 109 175.002380 $8750.1300 $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 18 18 32.066666 $1603.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 13.147619 $328.6900 $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
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.714286 $585.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 18 73.242861 $3662.1400 $50.0000
INTR -INTR INTERPRETER 57 96 290.578570 $14528.9200 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 14.000000 $950.3200 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 26 25.733333 $25.7300 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 4 45.285714 $3073.9900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 561 807 4056.342879 $2028.1800 $0.5000
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Subtotal (Total Children Is Unduplicated) 600 1173 4937.066687 $44721.4200 $9.0600
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Total 1342 5267.316687 $63280.4200 $12.0100
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Number of Children (Unduplicated) With at Least One Authorization 656