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
Eligibility Filter: Program Patients
With the filters selected there were 2289 FSPSA's found of which 17 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 1 1 2.233333 $82.6300 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.233333 $82.6300 $37.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.008219 $0.4100 $49.8800
EXIT -EXIT EXIT ASSESSMENT 4 4 1.166666 $58.3300 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 1.079756 $55.1200 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.066667 $10.0100 $150.0700
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.044444 $2.2700 $51.0000
SCREEN-T1023 SCREENING 7 7 2.522678 $126.1300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.057534 $2.9400 $51.0200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.055556 $53.8900 $51.0500
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Subtotal (Total Children Is Unduplicated) 17 19 6.001520 $309.0800 $51.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.288889 $1444.5000 $5000.1900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 6 10.066666 $503.3300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 117 53.630144 $2681.5100 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 398 1110 2514.048345 $125702.7000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 29 32 203.403176 $10170.1600 $50.0000
INTR -T1013 INTERPRETER 6 8 36.766669 $1838.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 4 34.552381 $345.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 17 118.407141 $8459.0100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 3 9.638096 $551.3000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 10 15 121.004762 $8644.5800 $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 45 57 339.465475 $24251.4000 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 436 809 8686.119186 $4343.0500 $0.5000
TRAV -TRAVS Travel by mile 62 89 1037.068249 $461.4900 $0.4400
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Subtotal (Total Children Is Unduplicated) 599 2269 13177.602036 $190148.1300 $14.4300
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Total 2289 13185.836889 $190539.8400 $14.4500
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Number of Children (Unduplicated) With at Least One Authorization 599