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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1216 FSPSA's found of which 30 had no frequency modifier field, FORCE FREQ MODIFIER to 0
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 2.783483 $135.0000 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 3 0.008220 $0.4100 $49.2700
EXIT -EXIT EXIT ASSESSMENT 17 17 8.332200 $416.6200 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 15 15 0.082185 $6.1900 $75.2900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 0.016437 $1.2400 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 34 0.180809 $10.0700 $55.6700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 6 0.028766 $2.1600 $75.0900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 2 2 0.532040 $27.1600 $51.0600
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 30 31 11.038487 $1655.8100 $150.0000
SCREEN-T1023 SCREENING 2 2 0.211035 $10.5600 $50.0200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 3.285714 $167.7400 $51.0500
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Subtotal (Total Children Is Unduplicated) 93 126 26.504855 $2433.3400 $91.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 2.960578 $14803.0000 $5000.0400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 35 6.649746 $332.4500 $49.9900
CONIF -CONIF CONSULT, FACE TO FACE 66 120 193.540765 $9677.0600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 26.000000 $650.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 39 41 196.284757 $9814.2300 $50.0000
INTR -T1013 INTERPRETER 12 16 8.725537 $436.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 152 211 1756.700283 $17566.9600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 11 111.285715 $7950.2500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 8 48.571429 $3469.9300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 139.785714 $9986.2900 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 143 225 822.362771 $411.1800 $0.5000
TRAV -TRAVS Travel by mile 227 393 37716.854146 $16784.0100 $0.4500
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Subtotal (Total Children Is Unduplicated) 367 1090 41029.721441 $91881.6400 $2.2400
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Total 1216 41056.226296 $94314.9800 $2.3000
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Number of Children (Unduplicated) With at Least One Authorization 375