Summary Report for FSPSAs Ending During the Report Period Center: 57
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 1034 FSPSA's found of which 7 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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.316666 $67.2100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 1.872221 $95.5700 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 1.917807 $97.9000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 1.938888 $98.9800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 22 5.280214 $269.5600 $51.0500
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Subtotal (Total Children Is Unduplicated) 37 49 12.325796 $629.2200 $51.0500
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 162 207 124.691278 $6234.6100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 12 98.428571 $4921.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 333 714 2461.295871 $24612.9700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 19.892857 $1421.1400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.571429 $261.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 5 5 46.571428 $3327.0600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 6.285714 $359.2900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 55.321429 $3952.1600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 10 12 139.140476 $69.5700 $0.5000
TRAV -TRAVS Travel by mile 13 15 95.000002 $42.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 364 985 3054.627626 $45398.1100 $14.8600
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Total 1034 3066.953422 $46027.3200 $15.0100
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Number of Children (Unduplicated) With at Least One Authorization 380