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
Eligibility Filter: Program Patients
With the filters selected there were 1805 FSPSA's found of which 52 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 13 13 3.202661 $155.3300 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 0.293151 $6.4300 $21.9500
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 5 5 0.200305 $10.0100 $49.9700
EXIT -EXIT EXIT ASSESSMENT 17 17 8.332200 $416.6200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 2.868101 $215.1100 $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 96 96 0.522190 $39.2800 $75.2200
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 17 17 0.084927 $6.3800 $75.1500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 107 108 2.334996 $129.6700 $55.5300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 29 0.152044 $11.4400 $75.2200
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 0.948707 $48.4400 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.486834 $24.8600 $51.0600
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 32 33 11.241226 $1686.2300 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.416667 $21.2700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 0.745510 $38.0600 $51.0500
SCREEN-T1023 SCREENING 3 3 2.811035 $140.5600 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.694466 $188.6000 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.191781 $9.5900 $50.0000
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Subtotal (Total Children Is Unduplicated) 199 349 40.029082 $3233.7900 $80.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 21 6.580286 $32901.0000 $4999.9300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 35 6.649746 $332.4500 $49.9900
CONIF -CONIF CONSULT, FACE TO FACE 66 120 193.540765 $9677.0600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 153.571428 $3839.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 174 192 1047.452139 $52372.5900 $50.0000
INTR -T1013 INTERPRETER 12 16 8.725537 $436.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 153 212 1762.700283 $17626.9600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 56 471.400000 $33676.8200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 70 76 588.490477 $42041.7500 $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 90 98 592.092859 $42299.1000 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 144 226 832.219914 $416.1100 $0.5000
TRAV -TRAVS Travel by mile 227 393 37716.854146 $16784.0100 $0.4500
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Subtotal (Total Children Is Unduplicated) 400 1455 43399.628656 $253547.0000 $5.8400
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Total 1804 43439.657738 $256780.7800 $5.9100
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Number of Children (Unduplicated) With at Least One Authorization 410