Summary Report for FSPSAs Ending During the Report Period Center: 05
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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 295 FSPSA's found of which 15 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
EXIT -EXIT EXIT ASSESSMENT 13 13 2.190488 $109.5300 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.411111 $30.8300 $75.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.169863 $8.6700 $51.0600
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Subtotal (Total Children Is Unduplicated) 15 15 2.771462 $149.0400 $53.7800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 10.209133 $510.4600 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 51 93 112.180833 $5609.0400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 21.857143 $546.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 15 77.176189 $3858.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 89 125 590.382538 $5903.8300 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 3.000000 $214.3200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 18.285714 $1306.3300 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 19 24 144.355554 $72.1800 $0.5000
TRAV -TRAVS Travel by mile 1 1 4.857143 $2.1600 $0.4400
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Subtotal (Total Children Is Unduplicated) 137 280 982.304247 $18023.5600 $18.3500
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Total 295 985.075709 $18172.5900 $18.4500
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Number of Children (Unduplicated) With at Least One Authorization 144