Summary Report for FSPSAs Ending During the Report Period Center: 52
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 729 FSPSA's found of which 6 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 1 1 0.344444 $17.2200 $49.9900
SCREEN-T1023 SCREENING 1 1 0.122222 $6.1100 $49.9900
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Subtotal (Total Children Is Unduplicated) 2 2 0.466666 $23.3300 $49.9900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.233333 $111.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 69 21.937753 $1096.8900 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 129 290 496.484806 $24824.2800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 28.692857 $1434.6400 $50.0000
INTR -T1013 INTERPRETER 3 4 11.852382 $592.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 2 2.133334 $21.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 0.775000 $55.3700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 9.857143 $704.1900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 28.129761 $2009.5900 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 168 316 2496.192923 $1248.1000 $0.5000
TRAV -TRAVS Travel by mile 20 30 258.249210 $114.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 222 727 3356.538502 $32213.5900 $9.6000
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Total 729 3357.005168 $32236.9200 $9.6000
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Number of Children (Unduplicated) With at Least One Authorization 222