Summary Report for FSPSAs Ending During the Report Period Statewide
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: 07-01-14 and 09-30-14 Date of Report: 11-19-14 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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 3 3 2.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.088889 $4.3100 $48.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.422222 $20.4800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.200000 $9.7000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 0.883334 $42.8400 $48.5000
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Subtotal (Total Children Is Unduplicated) 8 11 1.594445 $77.3300 $48.5000
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 19 19 9.438890 $471.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 22.886510 $1144.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 11.283334 $564.1700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 111 47.888097 $2394.4100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 10 30.730157 $1536.5100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 12.857143 $872.7400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 7 7 26.509524 $1799.4600 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 0.766667 $38.3400 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 29.252381 $1985.6500 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 271 397 1152.233333 $11522.3400 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 24 51 2628.196032 $1314.1000 $0.5000
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Subtotal (Total Children Is Unduplicated) 310 672 3972.042068 $23644.0000 $5.9500
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Total 686 3976.147624 $23721.3300 $5.9700
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Number of Children (Unduplicated) With at Least One Authorization 313