Summary Report for FSPSAs Initiated During the Report Period Center: 52
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
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 29 36.428571 $1766.7900 $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 18 23 23.000000 $1115.5000 $48.5000
SCREEN-T1023 INTERDISCIPLINARY SCREENING 21 22 22.000000 $1100.0000 $50.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 59 71 71.000000 $3443.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 102 147 154.428571 $7534.2900 $48.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 6 8.000000 $12000.0000 $1500.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 64 82 105.919043 $5295.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 39 51.199999 $2560.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 38 46.533334 $2326.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 82 133.290479 $6664.5400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 3 17.999999 $450.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 5 8.928571 $446.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 4.428571 $221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 79 105 357.547617 $17877.4000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 7 8 37.785714 $1889.2900 $50.0000
INTR -INTR INTERPRETER 7 7 66.428572 $3321.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 27 132.142858 $8969.8500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 38 45 230.898811 $15673.3900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 4 5.285714 $287.1200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 2.777777 $2.7800 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 6.714286 $335.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 125 549.487694 $37299.2700 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.535714 $46.6700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 160 246 83282.228561 $41641.1200 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 12.942857 $647.1400 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 1.000000 $50.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 195 839 85065.076171 $158006.1600 $1.8600
-------------------------------------------------------------------------------------------------------------------------------------
Total 986 85219.504742 $165540.4500 $1.9400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 214