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
EXIT -EXIT EXIT ASSESSMENT 17 17 3.130747 $156.5300 $50.0000
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Subtotal (Total Children Is Unduplicated) 17 17 3.130747 $156.5300 $50.0000
EI Services, Class # 03
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 4 15.336507 $766.8300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 24.714285 $1677.6100 $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) 63 128 5037.200001 $12660.5400 $2.5100
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Total 149 5043.063288 $12817.0700 $2.5400
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Number of Children (Unduplicated) With at Least One Authorization 81