Summary Report for FSPSAs Initiated During the Report Period Center: 05
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
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 7.000000 $875.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 30 31 61.000000 $3050.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $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 57 57 114.000000 $8550.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 34 34 68.000000 $5100.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 30 60.000000 $3330.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 62 63 126.000000 $9450.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 12.000000 $582.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 5.000000 $242.5000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 11.000000 $533.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 143 262 496.000000 $34035.0000 $68.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 11.000000 $16500.0000 $1500.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 169 336 1016.833319 $50841.6100 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 161 182 1980.428571 $99021.5000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 6.857143 $171.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 51 531.500000 $26575.0300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 13.428571 $335.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 76 84 1033.357139 $51667.9100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 25.428571 $635.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 123 1302.642860 $65132.1800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.000000 $50.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 19 115.514286 $2887.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 161 172 1068.333341 $53416.6300 $50.0000
INTR -INTR INTERPRETER 7 8 21.714286 $1085.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 15 45.273810 $3073.1900 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 17.840477 $969.0900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 43 45 171.211907 $11621.8600 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 10.785714 $585.8800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 38.000000 $38.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 69 311.995239 $21178.2100 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 193 381 226739.390473 $113369.6900 $0.5000
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Subtotal (Total Children Is Unduplicated) 220 1518 234463.535707 $519157.1900 $2.2100
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Total 1780 234959.535707 $553192.1900 $2.3500
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Number of Children (Unduplicated) With at Least One Authorization 261