Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 4 4 9.293651 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 9.293651 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.505556 $121.5200 $48.5000
EXIT -EXIT EXIT ASSESSMENT 12 15 17.780821 $889.0400 $50.0000
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Subtotal (Total Children Is Unduplicated) 15 18 20.286377 $1010.5600 $49.8100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 0.583257 $29.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 4 15.649208 $782.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 38 172 188.095830 $9404.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 20.979366 $1048.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.000000 $75.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 21.088889 $1054.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 20.749207 $1037.4600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.071429 $101.7900 $25.0000
INTR -INTR INTERPRETER 3 3 24.142857 $1207.1500 $50.0000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 95 249 78337.319918 $39168.6600 $0.5000
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Subtotal (Total Children Is Unduplicated) 101 467 78635.685517 $53910.0100 $0.6900
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Total 489 78665.265545 $54920.5700 $0.7000
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Number of Children (Unduplicated) With at Least One Authorization 114