Summary Report for FSPSAs Ending During the Report Period Center: 04
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 1719 FSPSA's found of which 1 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.100002 $3.7000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.100002 $3.7000 $37.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.449392 $21.8000 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.183333 $8.5800 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.733333 $87.7000 $119.5900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 17 18 3.499999 $178.6700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 30 30 13.163492 $672.0000 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 30 31 6.088890 $310.8400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 18.386509 $938.6400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 37 38 59.783332 $3051.9400 $51.0500
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Subtotal (Total Children Is Unduplicated) 109 143 102.288280 $5270.1700 $51.5200
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.100000 $55.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 22 2.666666 $133.3300 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 2 2 1.033334 $51.6700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 64 77 451.571432 $11289.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 564 607 3534.186074 $176709.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 523 604 3411.612523 $34116.1300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 89 391.550790 $27972.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 18.642857 $1066.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 69 73 355.050002 $25364.7600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 49.857144 $2849.8300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.366667 $86.9500 $237.1400
SENS -V5264 EARMOLD 1 1 0.733333 $13.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 80 308.826986 $22062.6000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.714286 $384.0600 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 12.142858 $168.5400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 1 8.285714 $4.1400 $0.5000
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Subtotal (Total Children Is Unduplicated) 700 1575 8554.340666 $302327.6200 $35.3400
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Total 1719 8656.728948 $307601.4800 $35.5300
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Number of Children (Unduplicated) With at Least One Authorization 703