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 8 8 2.211112 $107.2400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.500000 $24.2500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.488889 $23.7100 $48.5000
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Subtotal (Total Children Is Unduplicated) 11 11 3.200001 $155.2000 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 24 24 132.428571 $6621.4200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 22.071428 $1498.2100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 4 4 19.071428 $1294.5700 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.483333 $24.1700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 5.142857 $349.0900 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 472 598 4061.287281 $2030.6400 $0.5000
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Subtotal (Total Children Is Unduplicated) 484 685 4274.705529 $13529.1100 $3.1600
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Total 702 4280.966641 $13684.3100 $3.2000
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Number of Children (Unduplicated) With at Least One Authorization 494