Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 1 1 1.000000 $48.5000 $48.5000
EXIT -EXIT TRANSITION ASSESSMENT 23 23 46.000000 $2300.0000 $50.0000
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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 28 31 60.000000 $3220.5000 $53.6800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 15.502740 $775.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 3.500000 $87.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 20 24.133333 $1206.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 10.316667 $515.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 13 17.700000 $885.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.683333 $17.0800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 4 18.285715 $914.2800 $50.0000
INTR -INTR INTERPRETER 6 9 11.000000 $550.0000 $50.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 8 8 8.000000 $8.0000 $1.0000
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Subtotal (Total Children Is Unduplicated) 52 82 109.121788 $4959.5000 $45.4500
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Total 113 169.121788 $8180.0000 $48.3700
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Number of Children (Unduplicated) With at Least One Authorization 70