Summary Report for FSPSAs Ending During the Report Period Center: 06
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 1155 FSPSA's found of which 7 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 30 30 40.122780 $1484.5500 $37.0000
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Subtotal (Total Children Is Unduplicated) 30 30 40.122780 $1484.5500 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.295890 $35.3900 $119.6000
EXIT -EXIT EXIT ASSESSMENT 14 14 9.598563 $479.9300 $50.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 2.888889 $433.3400 $150.0000
SCREEN-T1023 SCREENING 6 6 6.333333 $316.6700 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.213698 $10.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 25 26 19.330373 $1276.2300 $66.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.084932 $424.5000 $4998.1200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.200000 $10.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 4.755556 $237.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 94 95 6.422620 $321.2100 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.172222 $4.3100 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 34 69 91.669046 $4583.4600 $50.0000
CONIP -CONIP CONSULT, PHONE 9 18 23.000000 $575.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 107 114 699.195238 $34959.7600 $50.0000
INTR -T1013 INTERPRETER 24 24 33.546372 $1677.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 498 633 3583.449159 $35834.4900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 23 64.038096 $4574.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 13.457143 $769.7500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 17 20 65.821429 $4702.2800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 14.464286 $826.7700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 15.428571 $3658.4300 $237.1200
SENS -V5264 EARMOLD 2 2 2.666667 $48.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 71 240.571427 $17186.4200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 146.500000 $2033.4200 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
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Subtotal (Total Children Is Unduplicated) 549 1099 5053.442764 $112451.7800 $22.2500
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Total 1155 5112.895917 $115212.5600 $22.5300
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Number of Children (Unduplicated) With at Least One Authorization 586