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: 04-01-13 and 06-30-13 Date of Report: 08-18-13 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 1 1 2.071429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.071429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 0.211111 $10.5600 $50.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.211111 $10.5600 $50.0000
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.714286 $35.7200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 23 125 63.329164 $3166.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 3.033333 $151.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 3.628571 $181.4300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 1.199999 $60.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1 1 0.266667 $13.3400 $50.0100
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.000000 $195.0000 $65.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 38 118 8450.752381 $4225.3800 $0.5000
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Subtotal (Total Children Is Unduplicated) 43 263 8525.924401 $8028.9600 $0.9400
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Total 265 8528.206941 $8039.5200 $0.9400
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Number of Children (Unduplicated) With at Least One Authorization 43