Summary Report for FSPSAs Ending During the Report Period Center: 06
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 598 FSPSA's found of which 4 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 24 24 33.300557 $1232.1200 $37.0000
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Subtotal (Total Children Is Unduplicated) 24 24 33.300557 $1232.1200 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 3 3 0.271233 $13.5600 $49.9900
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.288889 $193.3400 $150.0000
SCREEN-T1023 SCREENING 4 4 3.266666 $163.3300 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.213698 $10.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 11 11 5.040486 $381.1300 $75.6100
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.200000 $10.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 64 65 4.855839 $242.8500 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.172222 $4.3100 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 20 42 60.697618 $3034.8900 $50.0000
CONIP -CONIP CONSULT, PHONE 8 16 20.900000 $522.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 10 10 74.666665 $3733.3400 $50.0000
INTR -T1013 INTERPRETER 19 19 33.518977 $1675.9600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 300 382 2176.933565 $21769.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 16.861904 $1204.6100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.100000 $348.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 10.488096 $749.2700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 7.857143 $449.1100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 22.714286 $1622.7100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 53.214286 $738.6100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
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Subtotal (Total Children Is Unduplicated) 332 563 2537.180601 $36130.4000 $14.2400
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Total 598 2575.521644 $37743.6600 $14.6500
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Number of Children (Unduplicated) With at Least One Authorization 360