Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 13 24.500000 $1359.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 10.000000 $485.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 4.000000 $194.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.000000 $242.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 16 16 16.000000 $776.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 48 50 63.500000 $3315.7500 $52.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 11.000000 $16500.0000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 140 168 164.142857 $8207.1500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 133 145 243.015870 $12150.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 62 106.880950 $5344.0300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 66 77 123.679363 $6183.9600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 152 166 256.696823 $12834.8300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 20 135.000001 $6750.0000 $50.0000
INTR -INTR INTERPRETER 23 41 288.509524 $14425.4800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 10 73.571429 $4994.0300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 9 10 52.658730 $3574.4700 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 37 39 39.000000 $39.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 21 118.861904 $8068.3600 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 52 62 26166.952383 $13083.4800 $0.5000
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Subtotal (Total Children Is Unduplicated) 294 826 27780.469834 $112168.0600 $4.0400
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Total 876 27843.969834 $115483.8100 $4.1500
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Number of Children (Unduplicated) With at Least One Authorization 308