Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.000000 $150.0000 $150.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 5 6 10.000000 $709.5000 $70.9500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.000000 $100.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 5.000000 $250.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 56 62 71.209523 $3560.4800 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 10 10 11.400000 $285.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 22.400000 $1120.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 6.366667 $159.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 13.000000 $650.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 25.238095 $1261.9000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 6.000000 $150.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 22.285714 $1114.2900 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
SCONLY-SCONLY SERVICE COORDINATION ONLY 35 35 34.377778 $34.3800 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 10.285714 $698.1900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 53 56 7474.228573 $3737.1100 $0.5000
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Subtotal (Total Children Is Unduplicated) 147 233 7708.792064 $13345.5100 $1.7300
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Total 239 7718.792064 $14055.0100 $1.8200
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Number of Children (Unduplicated) With at Least One Authorization 148