Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 4324 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 2 2 0.319054 $11.8100 $37.0100
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Subtotal (Total Children Is Unduplicated) 2 2 0.319054 $11.8100 $37.0100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 2.260503 $109.6300 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 0.511111 $23.9200 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 1.388889 $166.1100 $119.6000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 37 43 25.748410 $1314.4500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 97 101 56.728569 $2895.9900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 61 68 20.211109 $1031.7700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 80 83 110.917331 $5662.3300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.511111 $26.0900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 90 109 105.532534 $5387.4200 $51.0500
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Subtotal (Total Children Is Unduplicated) 277 416 323.809567 $16617.7200 $51.3200
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 2 3.066667 $153.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 41 27.923809 $1396.1900 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 6 13 3.188887 $159.4400 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 9.571429 $239.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 157 195 1785.785703 $44644.7300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1246 1503 12377.353160 $618868.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1183 1488 12462.926718 $124629.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 176 219 1516.869838 $108365.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 11 80.785714 $4620.9500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 162 199 1470.230949 $105033.4100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 16 17 124.571430 $7120.5100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 2 1.022223 $242.4100 $237.1400
SENS -V5264 EARMOLD 1 2 1.388889 $25.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 162 202 1290.904769 $92222.3000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 12.642857 $723.1700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 45.939683 $637.6400 $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) 1550 3906 31222.458439 $1109085.9500 $35.5200
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Total 4324 31546.587060 $1125715.4800 $35.6800
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Number of Children (Unduplicated) With at Least One Authorization 1551