Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 10-01-12 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 3 3 7.277777 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 7.277777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 8 8 8.822222 $441.1100 $50.0000
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Subtotal (Total Children Is Unduplicated) 8 8 8.822222 $441.1100 $50.0000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 34.642857 $1732.1500 $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 28 155 361.455558 $18072.7900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 25.500000 $1275.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 24.834921 $1241.7500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 24.605555 $1230.2800 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.800000 $58.6600 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 9.152381 $457.6200 $50.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 79 196 56564.106343 $28282.0500 $0.5000
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Subtotal (Total Children Is Unduplicated) 82 402 57045.180953 $52354.3300 $0.9200
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Total 413 57061.280952 $52795.4400 $0.9300
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Number of Children (Unduplicated) With at Least One Authorization 85