Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 04-01-12 and 06-30-12 Date of Report: 08-16-12 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 5 5 5.000000 $242.5000 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.000000 $60.0000 $60.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 12 12 17.000000 $850.0000 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 19 21 26.000000 $1376.0000 $52.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 18.666666 $933.3300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 21 24 37.285714 $1864.2900 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 4 4 5.266667 $131.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 28.100000 $1405.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.133333 $28.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 50 65.800795 $3290.0400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.800000 $145.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 32 69.666668 $3483.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 11.571429 $289.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 10.066667 $251.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 6 22.876190 $1143.8100 $50.0000
INTR -INTR INTERPRETER 1 1 2.666667 $133.3400 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 3 11.714285 $795.1700 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 5.033334 $5.0300 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.208219 $13.5300 $64.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.133333 $212.6900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 93 159 28934.942859 $14467.4700 $0.5000
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Subtotal (Total Children Is Unduplicated) 162 327 29236.932826 $30167.9900 $1.0300
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Total 348 29262.932826 $31543.9900 $1.0800
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Number of Children (Unduplicated) With at Least One Authorization 164