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 1041 FSPSA's found of which 251 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 8 8 3.936833 $190.9300 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.493151 $58.9900 $119.6100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.411111 $20.9900 $51.0500
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Subtotal (Total Children Is Unduplicated) 10 10 4.841095 $270.9100 $55.9600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.219178 $1096.0000 $5000.5000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 164 189 2.728012 $136.5800 $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 68 71 418.150791 $20907.5300 $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 6 6 49.571429 $3541.3800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 49.485714 $3535.2500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 135.507145 $9680.6300 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 296 568 718.187299 $359.0900 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.666667 $0.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 429 1030 1670.403143 $53704.6000 $32.1500
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Total 1040 1675.244238 $53975.5100 $32.2200
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Number of Children (Unduplicated) With at Least One Authorization 432