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: 10-01-12 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 9 9 6.250001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 6.250001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 8 2.627778 $127.4500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.788889 $38.2600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.300000 $14.5500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 1 1 0.305556 $14.8200 $48.5100
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Subtotal (Total Children Is Unduplicated) 12 13 4.022223 $195.0800 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.511111 $766.6500 $1499.9700
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 8.656349 $432.8200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 3 3 4.838889 $241.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 11.888890 $594.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 20 15.500000 $775.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 10.422222 $521.1100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 23 24 132.428573 $6621.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 29.428571 $1997.6100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 3 3 19.571429 $1328.5100 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.888889 $57.7800 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.988889 $49.4500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.285714 $223.0300 $67.8800
TRAN -TRAN FAMILY TRANSPORTATION 2 2 22.428572 $2242.8500 $100.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 508 609 5348.120666 $2674.0600 $0.5000
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Subtotal (Total Children Is Unduplicated) 516 699 5608.958764 $18526.6900 $3.3000
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Total 721 5619.230988 $18721.7700 $3.3300
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Number of Children (Unduplicated) With at Least One Authorization 529