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 2360 FSPSA's found of which 387 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 26 31 16.454586 $798.0500 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.158904 $7.4400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.493151 $58.9900 $119.6100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.922222 $47.0800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.611111 $31.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 1.471688 $75.1300 $51.0500
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Subtotal (Total Children Is Unduplicated) 37 45 20.111662 $1017.8800 $50.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 1.160426 $5802.5000 $5000.3200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 169 196 6.672456 $333.8000 $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 210 225 1825.861891 $91293.2400 $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 22 25 271.968252 $19429.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 18 19 159.642857 $11404.9000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 47 465.865873 $33281.4900 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 424 833 1232.511129 $616.2600 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.666667 $0.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 709 2314 6631.423602 $291956.8400 $44.0300
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Total 2359 6651.535264 $292974.7100 $44.0500
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Number of Children (Unduplicated) With at Least One Authorization 712