Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 2.732540 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 2.732540 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 0.575647 $34.5400 $60.0100
EXIT -EXIT EXIT ASSESSMENT 17 17 3.130747 $156.5300 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.060274 $2.9200 $48.5200
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 0.277778 $13.4700 $48.5000
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Subtotal (Total Children Is Unduplicated) 23 23 4.044446 $207.4700 $51.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.733333 $13666.5000 $4999.9400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 6.428572 $321.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.944444 $23.6100 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 31 35 45.042859 $2252.1600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 25 42.655556 $2132.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.944444 $23.6100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 8.799999 $440.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 35 52.047620 $2602.3900 $50.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 861.142858 $10764.2900 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 21.428572 $535.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 102 104 584.427776 $29221.4200 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 5.142857 $257.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 149.271431 $10132.5500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 24 24 136.485717 $9264.6400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 11.785714 $640.2000 $54.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 34 199.747618 $13558.8800 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 14 17 4840.285715 $2420.1400 $0.5000
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Subtotal (Total Children Is Unduplicated) 156 322 6969.315085 $98257.4300 $14.1000
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Total 349 6976.092071 $98464.9000 $14.1100
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Number of Children (Unduplicated) With at Least One Authorization 167