Summary Report for FSPSAs Initiated During the Report Period Center: 01
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 7155 FSPSA's found of which 12 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 3 2.311111 $85.5100 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.928571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 65 70 187.394439 $6933.5700 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 68 74 190.634121 $7019.0900 $36.8200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 24 19.912438 $965.7500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 91.000000 $1358.6300 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 91.000000 $1747.2000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 91.000000 $948.2200 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 91.000000 $1997.4500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 91.252055 $798.4600 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 91.252055 $1992.9500 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 91.000000 $2629.9000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 91.000000 $5927.7400 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 91.733333 $2341.9500 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.244444 $11.4400 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.244444 $29.2300 $119.5800
EVAL -96111 DEVELOPMENTAL EVALUATION 6 11 20.000000 $1000.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 177 201 380.631699 $19031.5800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.004110 $0.3100 $74.8200
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 3.009589 $167.0300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 22.039725 $1652.9800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 15.500000 $1162.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 4.504110 $337.8100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 46 46 45.442072 $2522.0400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 14 11.520549 $864.0400 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 33.022222 $1685.7800 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 5 6 0.761644 $114.2700 $150.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 68.000000 $3471.4000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.938889 $14.6500 $15.6000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0600 $51.0800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 41.494444 $2118.2900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.083333 $4.2500 $51.0300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 277 374 1591.258473 $56263.1600 $35.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 95.090183 $475452.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 19 21 84.287813 $4214.4000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 222 249 159.834198 $7991.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 1.133334 $28.3400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 167 373 953.993231 $47699.6900 $50.0000
CONIP -CONIP CONSULT, PHONE 7 17 27.533336 $688.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 3.071429 $76.7900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 247 303 2052.283293 $102614.3100 $50.0000
INTR -T1013 INTERPRETER 86 124 844.566860 $42228.3900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1426 2429 16056.136718 $160561.5300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 27 155.580951 $11114.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.857143 $220.6300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 44 342.233333 $24449.1400 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.521156 $163.8700 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.244444 $28.9800 $118.5400
SENS -V5264 EARMOLD 3 3 91.496499 $1646.9400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 94 113 1045.038089 $74657.6100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 100.642858 $1396.9200 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 167 204 1279.892574 $639.9500 $0.5000
TRAV -TRAVS Travel by mile 1485 2773 30214.112067 $13445.2900 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1608 6707 53513.549509 $969319.4600 $18.1100
-------------------------------------------------------------------------------------------------------------------------------------
Total 7155 55295.442103 $1032601.7100 $18.6700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1662