Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 4032 FSPSA's found of which 309 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 20 29 105.569050 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.107143 $3.9600 $36.9900
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Subtotal (Total Children Is Unduplicated) 21 30 105.676193 $3.9600 $0.0400
Screening, Eval, and Assessment, Class # 02
AACIO -92597GO AAC INITIAL EVAL BY LICENSED OT 1 1 0.005479 $0.5600 $103.0300
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 0.433333 $44.4700 $102.6200
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 23 7.807916 $378.6900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 16 16 6.377777 $300.3300 $47.0900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.355556 $7.8100 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.411111 $26.7800 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 0.698554 $17.8400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 71.523015 $3347.2800 $46.8000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 3 0.961795 $48.0900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 51 63.604155 $3180.2100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.010959 $0.8300 $75.2800
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 0.283333 $15.7200 $55.4900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 5 3.649999 $273.7500 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 5 0.760655 $57.0500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 10 2.304909 $127.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 2 0.756165 $56.7200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 2.038812 $113.1500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 2 0.756165 $56.7200 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.800000 $40.8400 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 21 24 20.395499 $3059.3100 $150.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 3.569559 $182.2300 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.633333 $9.8800 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.043836 $2.2400 $51.0100
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.966667 $49.3500 $51.0500
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Subtotal (Total Children Is Unduplicated) 142 174 189.159540 $11398.5600 $60.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 32 8.350076 $41751.0000 $5000.0700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.733333 $36.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 11.972222 $857.3300 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 48 28.566669 $1428.3400 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 322 421 505.234740 $25261.7600 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 4.666666 $116.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.833333 $45.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 13 65.027776 $3251.3800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 856 1163 7093.201932 $354660.3900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 617 1255 6588.338332 $65883.4200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 10 60.066667 $4291.1600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 42 52 337.750791 $24128.9600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 9.714286 $555.2700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 57.000000 $13515.8400 $237.1200
SENS -V5264 EARMOLD 4 5 117.933333 $2122.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 83 578.563672 $41332.6300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 17.571428 $243.8900 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 416 690 4483.951100 $2241.9700 $0.5000
TRAV -TRAVS Travel by mile 24 42 168.566664 $75.0100 $0.4400
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Subtotal (Total Children Is Unduplicated) 932 3828 20139.043020 $581800.3100 $28.8900
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Total 4032 20433.878753 $593202.8300 $29.0300
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Number of Children (Unduplicated) With at Least One Authorization 937