Summary Report for FSPSAs Initiated During the Report Period Center: 53
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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.000000 $194.0000 $48.5000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 11 11 18.000000 $900.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 15 17 24.000000 $1344.0000 $56.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 9 9 40.171430 $2008.5700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 25 31 52.509523 $2625.4700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 9 11 9.500000 $237.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 14.766667 $738.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 38 42.566667 $2128.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 27 35.966667 $1798.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.571429 $39.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 13.428571 $671.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 5 13.799999 $690.0000 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.000000 $67.8800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 1 1 11.571429 $628.5600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 12 8.422221 $8.4200 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.043836 $2.8500 $64.9500
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.000000 $203.6400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.571429 $152.7400 $13.2000
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Subtotal (Total Children Is Unduplicated) 115 163 269.889868 $16726.3500 $61.9700
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Total 180 293.889868 $18070.3500 $61.4900
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Number of Children (Unduplicated) With at Least One Authorization 124