Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 1531 FSPSA's found of which 11 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
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.008219 $0.4100 $49.8800
EXIT -EXIT EXIT ASSESSMENT 3 3 0.988888 $49.4400 $50.0000
SCREEN-T1023 SCREENING 1 1 0.122222 $6.1100 $49.9900
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.057534 $2.9400 $51.0200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 6 1.176863 $58.9000 $50.0400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 3.033333 $151.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 64 81 44.402832 $2220.1500 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 284 779 1783.805476 $89190.4900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 12 78.264287 $3913.2100 $50.0000
INTR -T1013 INTERPRETER 6 8 36.766669 $1838.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 2 2.133334 $21.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 5 30.228571 $2159.5300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 16.428572 $1173.6500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 13.142857 $751.2500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 13 82.094047 $5864.8000 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 304 571 6185.064309 $3092.5200 $0.5000
TRAV -TRAVS Travel by mile 32 49 621.744444 $276.6800 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 413 1525 8897.108731 $110653.6100 $12.4400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1531 8898.285594 $110712.5000 $12.4400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 413