Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 9 9 10.000000 $485.0000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 4.000000 $194.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 3.000000 $145.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 18 18 19.000000 $921.5000 $48.5000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.644444 $32.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 8 3.511111 $175.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 5.900001 $295.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 2.083332 $104.1600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13 14 82.069844 $4103.4900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 4 12.000001 $814.5500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 4 4 27.571429 $1871.5500 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 9 9 9.000000 $9.0000 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 18.285714 $1241.2400 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 1 1 0.285714 $28.5700 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 439 567 3057.788902 $1528.9000 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 455 624 3220.140492 $10254.2400 $3.1800
-------------------------------------------------------------------------------------------------------------------------------------
Total 642 3239.140492 $11175.7400 $3.4500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 459