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
Eligibility Filter: Program Patients
With the filters selected there were 4256 FSPSA's found of which 75 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 41 52 14.171862 $687.3400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 11 12 5.383260 $118.1600 $21.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 5.000001 $234.0000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 8.521853 $1019.2200 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 11 11 4.235618 $211.7800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 58 59 61.160467 $3058.0500 $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
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.100000 $5.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 13 14 56.419221 $2880.2000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 26 26 23.140466 $1181.3300 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 49 51 15.986432 $2398.0100 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 10 2.802664 $143.0800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 8.281910 $422.8000 $51.0500
SCREEN-T1023 SCREENING 11 12 5.110274 $255.5300 $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 30 30 21.683311 $1106.9400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.065753 $3.3600 $51.0900
VISF -92499 VISION EVALUATION FUNCTIONAL 3 3 0.695891 $34.8000 $50.0100
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Subtotal (Total Children Is Unduplicated) 317 570 238.891102 $14170.4900 $59.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 50 66 23.975744 $119879.5000 $5000.0300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 57 63 39.816663 $1990.8000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 6.690356 $167.2600 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 181 469 789.460018 $39473.1200 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 6.133334 $153.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 32 819.857141 $20496.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 374 505 3673.299559 $183665.1800 $50.0000
INTR -T1013 INTERPRETER 13 19 37.154108 $1857.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 390 685 5575.123316 $55751.2500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 127 156 1557.361570 $111258.0100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.571429 $1291.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 158 204 1838.212689 $131322.0400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 30.428571 $1739.3000 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.712329 $168.9000 $237.1100
SENS -V5264 EARMOLD 2 3 0.328767 $5.9200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 201 251 2334.710213 $166791.9200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 18.285714 $253.8100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 252 390 2107.258370 $1053.6300 $0.5000
TRAV -TRAVS Travel by mile 378 830 148977.551463 $66295.0200 $0.4500
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Subtotal (Total Children Is Unduplicated) 611 3686 167858.931354 $903614.2300 $5.3800
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Total 4256 168097.822456 $917784.7200 $5.4600
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Number of Children (Unduplicated) With at Least One Authorization 615