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
Eligibility Filter: Program Patients
With the filters selected there were 1031 FSPSA's found of which 25 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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 3.500000 $129.5000 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.500000 $129.5000 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 31 31 6.909209 $345.4700 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 0.613851 $46.0400 $74.9900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.202740 $15.2000 $74.9900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.478082 $35.8600 $75.0000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 7.235616 $542.6700 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 5.456491 $278.5600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 2.525570 $128.9400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 22 14.557534 $743.1800 $51.0500
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Subtotal (Total Children Is Unduplicated) 70 80 37.979093 $2135.9100 $56.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.189041 $945.0000 $4998.9200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.087671 $4.3900 $50.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 21 14.131356 $706.5800 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 81 149 197.383219 $9869.1800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 74.714287 $1867.8600 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 0.202740 $10.1400 $49.9900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 235 264 1459.321830 $72966.0800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 141 203 1113.274426 $11132.7500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 42 256.647653 $18334.9000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.285714 $302.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 47 47 252.361905 $18028.7300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 137 156 871.573818 $62265.2100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 16.714286 $231.9900 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 41 48 279.813434 $139.9100 $0.5000
TRAV -TRAVS Travel by mile 2 2 14.000000 $6.2300 $0.4500
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Subtotal (Total Children Is Unduplicated) 284 949 4555.701380 $196811.2800 $43.2000
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Total 1031 4597.180473 $199076.6800 $43.3000
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Number of Children (Unduplicated) With at Least One Authorization 309