Summary Report for FSPSAs Initiated During the Report Period Center: 09
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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 324 FSPSA's found of which 33 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 5 5 3.025875 $151.3000 $50.0000
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Subtotal (Total Children Is Unduplicated) 5 5 3.025875 $151.3000 $50.0000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 28 40 1.102731 $55.1300 $49.9900
CONIF -CONIF CONSULT, FACE TO FACE 21 31 27.052266 $1352.5900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 31 31 209.442860 $10472.1600 $50.0000
INTR -T1013 INTERPRETER 29 30 1146.214288 $57310.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 18 153.400000 $10958.9100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 20 20 127.019049 $9074.2500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 45 320.823808 $22919.6700 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 82 103 548.019110 $274.0100 $0.5000
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Subtotal (Total Children Is Unduplicated) 183 318 2533.074112 $112417.4300 $44.3800
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Total 323 2536.099987 $112568.7300 $44.3900
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Number of Children (Unduplicated) With at Least One Authorization 187