Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1464 FSPSA's found of which 261 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 14 17 12.129167 $588.2600 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.493151 $58.9900 $119.6100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.172602 $8.8100 $51.0500
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Subtotal (Total Children Is Unduplicated) 16 20 12.794920 $656.0600 $51.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.397260 $1986.5000 $5000.5000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 95 109 2.714900 $135.8400 $50.0300
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 0.012500 $0.3100 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 227 519 1636.501643 $81825.3600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 81 310.398410 $15519.9400 $50.0000
INTR -T1013 INTERPRETER 13 13 30.754551 $1537.7300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 47 105 75.828576 $758.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 63.231746 $4517.2900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 33.138095 $2367.3900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 15 99.325396 $7095.8100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 295 583 865.539693 $432.7700 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.666667 $0.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 462 1443 3118.509437 $116177.5200 $37.2500
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Total 1463 3131.304357 $116833.5800 $37.3100
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Number of Children (Unduplicated) With at Least One Authorization 465