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: 10-01-12 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 6 6 3.061111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 3.061111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 2.394446 $116.1400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 72 78 22.076984 $1070.7300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 65 68 17.577782 $852.5400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 40 41 9.099997 $441.3400 $48.5000
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Subtotal (Total Children Is Unduplicated) 159 197 51.149209 $2480.7500 $48.5000
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.050000 $2.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 10.736507 $536.8200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 13.588889 $679.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 17 9.845235 $492.2500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 50 54 325.285709 $8132.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 501 567 3386.481719 $169324.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 113 123 608.642851 $41314.6900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 113 125 633.357135 $42992.3600 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 11 11 19.587302 $979.3800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 85 390.285710 $26492.6100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.571429 $33.9400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 472 598 4061.287281 $2030.6400 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 7 45.200000 $2260.0100 $50.0000
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Subtotal (Total Children Is Unduplicated) 621 1623 9506.919767 $295270.8800 $31.0600
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Total 1826 9561.130087 $297751.6200 $31.1400
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Number of Children (Unduplicated) With at Least One Authorization 628