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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 11 12 22.876191 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 12 22.876191 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 16 4.127776 $200.1900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 4 0.805556 $39.0700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 0.688889 $33.4100 $48.5000
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Subtotal (Total Children Is Unduplicated) 22 23 5.622221 $272.6700 $48.5000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 5.857142 $292.8600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 27 9.688891 $484.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 29 14.566664 $728.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 10.566665 $528.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 17 18 69.642857 $3482.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 0.857143 $58.1800 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 5 6 33.714286 $2288.5200 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.383333 $24.9100 $64.9900
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.811111 $40.5600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 13.142857 $892.1400 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 545 658 5357.708755 $2678.8600 $0.5000
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Subtotal (Total Children Is Unduplicated) 550 753 5516.939704 $11499.2800 $2.0800
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Total 788 5545.438116 $11771.9500 $2.1200
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Number of Children (Unduplicated) With at Least One Authorization 566