Summary Report for FSPSAs Initiated During the Report Period Center: 02
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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3056 FSPSA's found of which 58 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 28 37 7.589671 $368.1000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 9 4.696806 $103.1000 $21.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 1.933334 $90.4800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 8.017743 $958.9300 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 7 7 4.144902 $207.2500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 41 42 56.407042 $2820.3700 $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 6 7 1.671384 $85.3200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 17 17 21.435823 $1094.3000 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 35 36 12.287801 $1843.2200 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 1.528387 $78.0300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 15 6.209307 $316.9900 $51.0500
SCREEN-T1023 SCREENING 6 6 3.331888 $166.6000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.142466 $7.2700 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 21 19.401880 $990.4700 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.504110 $25.2100 $50.0100
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Subtotal (Total Children Is Unduplicated) 218 382 154.812471 $9526.9900 $61.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 31 41 8.993704 $44968.0000 $4999.9400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 39 43 15.347917 $767.3600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 6.285714 $157.1400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 130 333 549.720331 $27486.1200 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 6.133334 $153.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 23 738.142856 $18453.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 310 420 3069.907494 $153495.5400 $50.0000
INTR -T1013 INTERPRETER 12 17 37.143150 $1857.1600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 287 506 4250.698202 $42506.9900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 86 105 1008.671422 $72059.5500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.571429 $1291.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 114 147 1329.733326 $94996.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 30.428571 $1739.3000 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.208219 $49.3700 $237.1000
SENS -V5264 EARMOLD 1 2 0.328767 $5.9200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 147 1308.589911 $93485.7700 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 190 284 1515.283197 $757.6400 $0.5000
TRAV -TRAVS Travel by mile 275 597 108375.027506 $48226.8900 $0.4500
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Subtotal (Total Children Is Unduplicated) 453 2674 122273.215050 $602456.9900 $4.9300
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Total 3056 122428.027521 $611983.9800 $5.0000
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Number of Children (Unduplicated) With at Least One Authorization 455