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 1708 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 2 2 1.411111 $52.2100 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.411111 $52.2100 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 3.142857 $204.7300 $65.1400
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 0.285714 $15.8600 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 0.285714 $21.4400 $75.0200
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 8.281746 $422.7900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 26 11.607934 $592.5800 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 25 25 8.075816 $412.2700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 13 13 3.661111 $186.9000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 74 76 21.735843 $1109.6100 $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) 121 156 59.248957 $3124.9600 $52.7400
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 212 280 172.748419 $8637.4600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.857143 $221.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 92 97 640.804764 $32040.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 486 1034 3578.787759 $35787.8900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 15 85.250001 $6090.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.857143 $506.6300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 23 23 182.857142 $13063.3100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 31.571428 $1804.6300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 59 310.890476 $22210.0200 $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) 550 1550 5316.366339 $120719.7300 $22.7100
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Total 1708 5377.026407 $123896.9000 $23.0400
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Number of Children (Unduplicated) With at Least One Authorization 578