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 1 1 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 30 31 61.000000 $3050.0000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 20.000000 $1110.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 18.000000 $1350.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 50 64 124.000000 $7405.5000 $59.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $4500.0000 $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 2 2 11.285714 $282.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 28 176.300000 $8815.0100 $50.0000
INTR -INTR INTERPRETER 7 8 21.714286 $1085.7200 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 7.571429 $513.9500 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 14 14 38.000000 $38.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 59.980954 $4071.5000 $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) 215 1226 232969.719030 $427107.0800 $1.8300
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Total 1290 233093.719030 $434512.5800 $1.8600
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Number of Children (Unduplicated) With at Least One Authorization 231