Summary Report for FSPSAs Initiated During the Report Period Center: 57
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
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 3 3 3.000000 $155.2800 $51.7600
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 14 14.000000 $679.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 36 36 33.922222 $1645.2300 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 31 31 29.844444 $1447.4500 $48.5000
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Subtotal (Total Children Is Unduplicated) 68 84 80.766666 $3926.9600 $48.6200
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 2 2 0.500000 $25.0000 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 6.834126 $341.7100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 26 20.675397 $1033.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 194 195 115.579358 $5778.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.477778 $11.9500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 31 195.142859 $4878.5700 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 3 3 8.571429 $214.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 259 261 1939.428564 $96971.4500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 36 181.499998 $12320.2300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 54 55 268.678574 $18237.9000 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 10 10 8.955555 $8.9600 $1.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.500000 $75.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 64 358.714288 $24349.5300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 12.785715 $168.7700 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 275 291 9283.525392 $4641.7600 $0.5000
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Subtotal (Total Children Is Unduplicated) 346 993 12403.869033 $169082.8100 $13.6300
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Total 1077 12484.635699 $173009.7700 $13.8600
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Number of Children (Unduplicated) With at Least One Authorization 348