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
Eligibility Filter: Program Patients
With the filters selected there were 2446 FSPSA's found of which 8 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 7 7 2.892963 $107.0400 $37.0000
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Subtotal (Total Children Is Unduplicated) 7 7 2.892963 $107.0400 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 3.309524 $215.5900 $65.1400
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 3.499999 $194.2600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 15 4.499998 $337.5200 $75.0100
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 14 14 9.776645 $499.0900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 49 51 18.739080 $956.6100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 44 44 16.772010 $856.2100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 33 33 9.349999 $477.3100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 137 141 48.291615 $2465.2900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.172222 $8.7900 $51.0400
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Subtotal (Total Children Is Unduplicated) 247 315 118.411092 $6310.6700 $53.2900
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 212 282 173.126197 $8656.3500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 36 251.428568 $6285.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 403 420 2876.299212 $143814.9600 $50.0000
INTR -T1013 INTERPRETER 1 1 1.285714 $64.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 494 1052 3649.740142 $36497.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 63 68 290.321429 $20740.5800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.857143 $506.6300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 82 82 428.888095 $30639.7700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 55.214286 $3156.0500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 139 704.140475 $50303.8500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.571429 $21.8100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 12 14 192.354761 $96.1800 $0.5000
TRAV -TRAVS Travel by mile 16 19 98.387303 $43.7800 $0.4500
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Subtotal (Total Children Is Unduplicated) 638 2124 8735.043325 $301023.4700 $34.4600
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Total 2446 8856.347380 $307441.1800 $34.7100
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Number of Children (Unduplicated) With at Least One Authorization 662