Summary Report for FSPSAs Ending During the Report Period Center: 55
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 13 13 9.996826 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 13 9.996826 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 1.138890 $55.2400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.172222 $8.3500 $48.4900
SPCH -92506 SPEECH EVAL BY LICENSED SLP 5 5 7.034126 $341.1500 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 12 12 8.375375 $406.2500 $48.5100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 0.350000 $17.5000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 0.010960 $0.5400 $49.2700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 3 0.505480 $12.6400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 14 14 8.866894 $443.3400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 20 20 30.033334 $750.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 12 3.308221 $165.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 14 15.766666 $394.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 0.438888 $21.9400 $49.9900
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.100000 $127.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 2.672221 $133.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 14.966667 $374.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2 2 13.571428 $678.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 13 52.142859 $3539.4500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 10.285715 $558.7200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 7 8 44.749999 $3037.6300 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.049315 $3.2000 $64.9800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 27 130.250003 $8841.3600 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 177 263 83509.881915 $41754.9400 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 184 413 83842.950565 $60855.5100 $0.7300
-------------------------------------------------------------------------------------------------------------------------------------
Total 438 83861.322766 $61261.7600 $0.7300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 199