Summary Report for FSPSAs Initiated During the Report Period Center: 09
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.400000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.400000 $0.0000 $0.0000
EI Services, Class # 03
CONIF -CONIF CONSULT ITDS, FACE TO FACE 835 1363 2042.438263 $102122.7400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 833 1350 2025.366840 $101269.2000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 834 1348 2031.147792 $101558.2400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 834 1361 2045.090648 $102255.3800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 387 445 2454.757147 $122737.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 64 77 406.565871 $27597.6900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 122 140 763.058728 $51796.4300 $67.8800
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 9 5.455555 $272.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 178 207 1036.760318 $70375.2900 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 372 1359 167746.004762 $83873.0000 $0.5000
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Subtotal (Total Children Is Unduplicated) 844 7659 180556.645924 $763858.6000 $4.2300
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Total 7660 180557.045924 $763858.6000 $4.2300
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Number of Children (Unduplicated) With at Least One Authorization 844