Summary Report for FSPSAs Ending During the Report Period Center: 51
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
Screening, Eval, and Assessment, Class # 02
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.000000 $175.0000 $87.5000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.857143 $142.8600 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 75 81 33.861113 $1693.0700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.475000 $11.8800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 19.331352 $966.5900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.050000 $1.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 42 22.059128 $1102.9700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.050000 $1.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 57 31.288495 $1564.4400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.983334 $49.5900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 7.857143 $392.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 8.257143 $560.4900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 1 1 0.400000 $27.1500 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.000000 $500.0000 $500.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 7.857143 $533.3400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 108 183 23162.941258 $11581.4700 $0.5000
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Subtotal (Total Children Is Unduplicated) 115 411 23300.268252 $19129.1800 $0.8200
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Total 413 23302.268252 $19304.1800 $0.8300
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Number of Children (Unduplicated) With at Least One Authorization 115