Summary Report for FSPSAs Ending During the Report Period Center: 10
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 34 35 16.333332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 34 35 16.333332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 8 3.766667 $226.0000 $60.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 2.311111 $112.0900 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 10 10 5.833333 $282.9200 $48.5000
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Subtotal (Total Children Is Unduplicated) 23 25 11.911111 $621.0100 $52.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.333333 $1666.5000 $4999.5000
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 4.071429 $203.5700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 109 80.902383 $4045.1300 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 66 68 29.444446 $1472.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 57 34.311112 $1715.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 65 40.111108 $2005.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 126 61.405554 $3070.2700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 22.933333 $573.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 66 74 431.233335 $21561.6800 $50.0000
INTR -INTR INTERPRETER 3 3 22.355555 $1117.7800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 37 136.622224 $9273.9300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 44 47 175.866665 $11937.8200 $67.8800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 58 286.833335 $19470.2600 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 504 718 3948.393658 $39483.9400 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 24 25 256.433334 $128.2200 $0.5000
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Subtotal (Total Children Is Unduplicated) 591 1397 5533.217471 $117811.5800 $21.2900
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Total 1457 5561.461914 $118432.5900 $21.3000
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Number of Children (Unduplicated) With at Least One Authorization 629