Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 13.333334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 13.333334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.082192 $4.9300 $60.0100
EVAL -EVAL DEVELOPMENTAL EVALUATION 2 2 0.009589 $0.4800 $50.0600
EXIT -EXIT EXIT ASSESSMENT 37 38 36.666287 $1833.3200 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 1.523554 $114.2600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 0.022222 $1.2300 $55.4400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 1.509589 $113.2200 $75.0000
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Subtotal (Total Children Is Unduplicated) 45 50 39.813433 $2067.4400 $51.9300
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.472222 $73.6100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 0.130254 $6.5100 $49.9400
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 20 45.652384 $2282.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 22 26.916668 $1345.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 30 49.272226 $2463.6300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 26.714285 $1335.7200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 1.800000 $90.0000 $50.0000
INTR -INTR INTERPRETER 12 16 2.502911 $125.1400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.000000 $203.6400 $67.8800
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Subtotal (Total Children Is Unduplicated) 66 113 157.460950 $7926.7200 $50.3400
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Total 174 210.607717 $9994.1600 $47.4500
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Number of Children (Unduplicated) With at Least One Authorization 110