Summary Report for FSPSAs Ending During the Report Period Center: 09
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 568 FSPSA's found of which 28 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 14 14 5.483485 $274.1800 $50.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.300000 $45.0000 $150.0000
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Subtotal (Total Children Is Unduplicated) 15 15 5.783485 $319.1800 $55.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.161904 $10809.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 63 1.157790 $57.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 23 34 26.177230 $1308.8500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 127 129 744.295243 $37214.7700 $50.0000
INTR -T1013 INTERPRETER 20 21 705.928573 $35296.4200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 44 326.328573 $23312.9200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 42 43 240.442862 $17177.2400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 120 729.761906 $52134.2100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 77 95 384.189490 $192.0900 $0.5000
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Subtotal (Total Children Is Unduplicated) 323 552 3160.449127 $177504.0200 $56.1600
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Total 567 3166.232612 $177823.2000 $56.1600
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Number of Children (Unduplicated) With at Least One Authorization 330