Summary Report for FSPSAs Initiated During the Report Period Center: 55
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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 2.000000 $97.0000 $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) 7 7 7.000000 $339.5000 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $4500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 5.711111 $285.5600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 2 2.400000 $60.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 6.788889 $339.4500 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 12 12 18.866666 $471.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 7.505555 $375.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.866666 $146.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.416667 $70.8400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.133333 $78.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 9.394444 $469.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 16.433333 $410.8300 $25.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 21.714286 $1473.9700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.142857 $605.2800 $54.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 2.285714 $124.1600 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 12 13 13.294445 $13.2900 $1.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 21 139.428570 $9464.4200 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 149 176 1544.621428 $772.3100 $0.5000
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Subtotal (Total Children Is Unduplicated) 165 283 1816.003964 $19811.7600 $10.9100
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Total 290 1823.003964 $20151.2600 $11.0500
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Number of Children (Unduplicated) With at Least One Authorization 166