Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2796 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 34 38 26.672218 $986.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 34 38 26.672218 $986.8600 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 0.443837 $20.7700 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 14 9.231507 $1104.1000 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 4 0.175342 $8.7700 $50.0200
EXIT -EXIT EXIT ASSESSMENT 5 5 0.090412 $4.5200 $49.9900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 0.143985 $10.8100 $75.0600
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 0.075341 $5.6600 $75.0600
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 0.268492 $20.1500 $75.0300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.010958 $0.6100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 203 207 3.660202 $274.8700 $75.1000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 84 84 0.649449 $48.8800 $75.2600
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 56 56 0.304085 $22.8900 $75.2800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 43 43 0.320683 $17.8400 $55.6400
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 58 58 0.649291 $48.7800 $75.1300
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 12 20.023483 $1022.1900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 1.814994 $92.6600 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 6.066667 $910.0100 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 12 14 13.492857 $688.8100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 0.978918 $49.9700 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 43 46 40.900501 $2087.9900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.233333 $11.9100 $51.0400
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Subtotal (Total Children Is Unduplicated) 328 588 99.534337 $6452.1700 $64.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.026104 $5130.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 6 6 3.961110 $198.0500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.444444 $72.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 27 34 16.609646 $830.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 11 7.800001 $195.0000 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 67 139 161.579405 $8078.9600 $50.0000
CONIP -CONIP CONSULT, PHONE 40 83 134.016270 $3350.4100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 17.714286 $442.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 131 155 1139.455895 $56972.8700 $50.0000
INTR -T1013 INTERPRETER 2 2 2.972146 $148.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 3 39.428571 $394.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 170 245 1371.438894 $97975.5200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 54 62 397.771033 $22752.5100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 142 227 1274.819053 $91072.9900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 30 36 200.466270 $11458.6500 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 1.380822 $327.4400 $237.1300
SENS -V5264 EARMOLD 14 17 12.981887 $233.6700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 482 640 4371.098182 $312271.4500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 11.874603 $164.8200 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 322 475 4120.098833 $2060.0400 $0.5000
TRAV -TRAVS Travel by mile 10 18 119.900795 $53.3600 $0.4500
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Subtotal (Total Children Is Unduplicated) 713 2170 13407.838250 $614184.6800 $45.8100
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Total 2796 13534.044805 $621623.7100 $45.9300
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Number of Children (Unduplicated) With at Least One Authorization 845