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
Eligibility Filter: Program Patients
With the filters selected there were 3106 FSPSA's found of which 409 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 29 35 26.628070 $1291.4600 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.304109 $14.2300 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 4.324888 $517.2700 $119.6000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 3.156469 $161.1400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 31.940965 $1630.5900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 23 26 12.046214 $614.9600 $51.0500
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Subtotal (Total Children Is Unduplicated) 86 107 78.400715 $4229.6600 $53.9500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 2.836911 $14185.5000 $5000.3300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 170 197 6.680789 $334.2100 $50.0300
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 0.013889 $0.3500 $25.0200
CONIF -CONIF CONSULT, FACE TO FACE 344 799 2545.405607 $127270.7000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 599 635 5487.484095 $274374.6800 $50.0000
INTR -T1013 INTERPRETER 15 15 32.683122 $1634.1600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 69 146 88.971433 $889.7200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 88 93 996.065768 $71159.0700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 88 95 947.652377 $67700.3600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 13.142857 $751.2500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 140 149 1401.322224 $100110.6100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 424 838 1253.931764 $626.9700 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.666667 $0.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 841 2983 12776.857503 $659037.8500 $51.5800
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Total 3090 12855.258218 $663267.5100 $51.6000
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Number of Children (Unduplicated) With at Least One Authorization 849