Summary Report for FSPSAs Ending During the Report Period Center: 02
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 1298 FSPSA's found of which 44 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 2.783483 $135.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.126028 $2.7700 $21.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.266667 $59.2800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.208219 $24.9000 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.172603 $8.6300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 11 11 6.077406 $303.8800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.862622 $214.7000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.016437 $0.9200 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 63 63 0.330116 $24.8300 $75.2200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 0.041095 $3.0800 $75.0100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 71 71 2.139118 $118.7700 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 22 0.115060 $8.6600 $75.2200
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.093151 $4.7600 $51.0800
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.347945 $17.7700 $51.0600
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 25 26 10.008349 $1501.3100 $150.0100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.323288 $16.5000 $51.0500
SCREEN-T1023 SCREENING 2 2 2.605556 $130.2800 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.694466 $188.6000 $51.0500
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Subtotal (Total Children Is Unduplicated) 136 236 33.217088 $2765.0300 $83.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 2.816816 $14083.5000 $4999.7900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 26 1.151451 $57.5400 $49.9700
CONIF -CONIF CONSULT, FACE TO FACE 48 82 133.148702 $6657.4600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 131.571428 $3289.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 148 163 919.700715 $45985.0300 $50.0000
INTR -T1013 INTERPRETER 11 14 8.714579 $435.7300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 113 156 1554.459901 $15544.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 39 302.447619 $21606.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 54 57 437.347620 $31244.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 19.142857 $1094.2100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.208219 $49.3700 $237.1000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 57 308.450001 $22035.6500 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 114 176 615.484233 $307.7400 $0.5000
TRAV -TRAVS Travel by mile 160 273 27176.423153 $12093.5100 $0.4500
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Subtotal (Total Children Is Unduplicated) 298 1061 31611.067294 $174484.5500 $5.5200
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Total 1297 31644.284382 $177249.5800 $5.6000
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Number of Children (Unduplicated) With at Least One Authorization 305