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: 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 7 7 7.000000 $339.5000 $48.5000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EXIT -EXIT TRANSITION ASSESSMENT 26 27 48.500000 $2425.0000 $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) 35 36 57.500000 $2938.0000 $51.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 6.000000 $9000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 54.204761 $2710.2400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 16 18 32.817460 $1640.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 52.652383 $2632.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 41 73.557144 $3677.8700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 35 63.185716 $3159.3100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.466667 $111.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 16.961904 $848.1000 $50.0000
INTR -INTR INTERPRETER 2 2 4.377778 $218.8900 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 3 10.571428 $717.5900 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 8.633332 $8.6300 $1.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.000000 $260.0000 $65.0000
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.714286 $115.0300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 209 421 75409.503174 $37704.7500 $0.5000
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Subtotal (Total Children Is Unduplicated) 225 584 75749.646033 $62805.5700 $0.8300
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Total 620 75807.146033 $65743.5700 $0.8700
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Number of Children (Unduplicated) With at Least One Authorization 226