Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-11 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 13 13 14.000000 $679.0000 $48.5000
EVAL -EVAL DEVELOPMENTAL EVALUATION 6 6 6.000000 $300.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 5.000000 $242.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.000000 $194.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 4 4 4.000000 $194.0000 $48.5000
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Subtotal (Total Children Is Unduplicated) 29 32 33.000000 $1609.5000 $48.7700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 0.944444 $47.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 5 1.866667 $93.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.622222 $31.1100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 18 103.355556 $5167.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 25.142857 $1706.6900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 2 2 14.142857 $960.0200 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 11 10.533333 $10.5300 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 36.928571 $2506.7100 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 422 559 2791.809525 $1395.9000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 2.357143 $117.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 442 613 2988.703175 $12087.1600 $4.0400
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Total 645 3021.703175 $13696.6600 $4.5300
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Number of Children (Unduplicated) With at Least One Authorization 453