Summary Report for FSPSAs Initiated During the Report Period Center: 03
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 18 19 19.000000 $1140.0000 $60.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 47 47 85.500000 $4745.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 5.000000 $375.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 4.000000 $194.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 7.000000 $339.5000 $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 6 6 6.000000 $291.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 23 23.000000 $1115.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 95 111 151.500000 $8297.2500 $54.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 8.000000 $12000.0000 $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 144 146 324.923810 $16246.1900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 42 85.617459 $4280.8700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 69 134.482541 $6724.1300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 148 152 269.715874 $13485.7900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 148 156 1103.100012 $55154.9600 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 24.476190 $1223.8100 $50.0000
INTR -INTR INTERPRETER 25 44 238.461903 $11923.1000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 33 251.000003 $17037.8700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 26 32 259.000000 $17580.9200 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 39 39 39.000000 $39.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 43 306.078572 $20776.6200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 184 266 117893.904760 $58946.9500 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 9 9 85.000001 $4250.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 290 1206 121187.403982 $247889.8500 $2.0500
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Total 1317 121338.903982 $256187.1000 $2.1100
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Number of Children (Unduplicated) With at Least One Authorization 311