Summary Report for FSPSAs Ending During the Report Period Center: 05
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.844444 $97.1100 $114.9900
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 6.000000 $750.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 33 38 79.000000 $3950.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 65 65 130.000000 $9750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 37 37 74.000000 $5550.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 41 41 82.000000 $4551.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 60 61 122.000000 $9150.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 10.000000 $485.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 2.000000 $97.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 11.000000 $533.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 159 289 553.844444 $37595.6100 $67.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 14.000000 $21000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.533333 $126.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 192 392 804.428571 $40221.4300 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 174 198 396.857143 $19842.8600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 65 130.214286 $6510.7200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 99 106 232.642857 $11632.1500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 140 280.857143 $14042.8600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 26 31 170.590479 $4264.7600 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 0.800000 $20.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 171 189 1058.980958 $52949.0100 $50.0000
INTR -INTR INTERPRETER 8 9 100.142857 $5007.1400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 21 73.338095 $4978.1800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.928572 $485.0000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 46 48 163.690476 $11111.2900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 4.714286 $256.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 20 20 33.428571 $33.4300 $1.0000
SENS -V5264 EARMOLD 1 1 0.844444 $15.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 75 327.795242 $22250.7000 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 7.800001 $102.9600 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 238 420 238825.380953 $119412.6900 $0.5000
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Subtotal (Total Children Is Unduplicated) 276 1733 242639.968267 $334313.1100 $1.3800
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Total 2022 243193.812711 $371908.7200 $1.5300
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Number of Children (Unduplicated) With at Least One Authorization 333