Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 425 476 616.692077 $30834.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 415 462 597.314298 $29865.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 426 473 619.447636 $30972.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 426 481 625.247635 $31262.4600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 13 108.571429 $5428.5800 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 3 12.285714 $833.9500 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 1.488889 $74.4500 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 3 18.996032 $1289.4600 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 76 278 32282.614286 $16141.3100 $0.5000
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Subtotal (Total Children Is Unduplicated) 432 2191 34882.657996 $146703.1100 $4.2100
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Total 2191 34882.657996 $146703.1100 $4.2100
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Number of Children (Unduplicated) With at Least One Authorization 432