Summary Report for FSPSAs Ending During the Report Period Center: 53
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
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 11 12 5.388890 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.866667 $32.0700 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 11 14 6.255557 $32.0700 $5.1300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.033333 $195.6200 $48.5000
EXIT -EXIT EXIT ASSESSMENT 28 28 20.857457 $1042.8700 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 33 33 24.890790 $1238.4900 $49.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 3.118265 $4677.3000 $1499.9700
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 17.284128 $864.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 12 0.077782 $3.9100 $50.2700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 50 189 252.163499 $12608.2100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 1.305555 $32.6400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 21 42.277779 $2113.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 23 32.442857 $1622.1500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.600000 $15.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 36 37 69.284923 $3464.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.000001 $175.0000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 2.466667 $180.8600 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5 6 13.609524 $680.4800 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 1.571428 $106.6700 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.155556 $140.1100 $65.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 187 489 75871.620565 $37935.8100 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 192 807 76316.984085 $64620.6400 $0.8500
-------------------------------------------------------------------------------------------------------------------------------------
Total 854 76348.130432 $65891.1900 $0.8600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 201