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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1279 FSPSA's found of which 264 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 9 9 11.651119 $565.0800 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 1.804338 $215.8200 $119.6100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.922222 $47.0800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 1.168645 $59.6600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.205555 $61.5400 $51.0500
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Subtotal (Total Children Is Unduplicated) 30 31 16.751879 $949.1800 $56.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 0.741401 $3707.5000 $5000.6700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 165 190 2.736345 $136.9900 $50.0600
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 0.013889 $0.3500 $25.0200
CONIF -CONIF CONSULT, FACE TO FACE 75 117 283.912701 $14195.6400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 199 1161.803171 $58090.1600 $50.0000
INTR -T1013 INTERPRETER 7 7 3.306349 $165.3200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 18 36 8.653969 $86.5400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 25 166.319049 $11881.8300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 26 190.428571 $13604.2100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 62 370.509526 $26469.2100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 296 569 719.820632 $359.9100 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.666667 $0.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 464 1239 2908.912270 $128697.9500 $44.2400
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Total 1270 2925.664149 $129647.1200 $44.3100
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Number of Children (Unduplicated) With at Least One Authorization 472