Summary Report for FSPSAs Ending During the Report Period Center: 03
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 8 8 17.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 17.733333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 19 4.488889 $217.7100 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.405556 $19.6700 $48.5100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.333333 $16.1700 $48.5000
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Subtotal (Total Children Is Unduplicated) 20 21 5.227778 $253.5500 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.272223 $6361.5000 $5000.3000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 179 179 268.364285 $13418.2100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 44 77.666668 $3883.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 81 109.733331 $5486.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 156 156 237.141276 $11857.0900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 26 54.931746 $2746.5900 $50.0000
INTR -INTR INTERPRETER 13 13 121.246032 $6062.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 42.285714 $2870.3600 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 13 13 75.123809 $5099.4100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.966667 $483.3500 $500.0200
SENS -V5264 EARMOLD 2 2 1.022223 $18.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 24.142856 $1638.8300 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 269 525 135581.952382 $67790.9800 $0.5000
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Subtotal (Total Children Is Unduplicated) 272 1052 136595.849212 $127717.0100 $0.9300
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Total 1081 136618.810323 $127970.5600 $0.9400
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Number of Children (Unduplicated) With at Least One Authorization 280