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 1348 FSPSA's found
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 15 17 11.833332 $437.8300 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 17 11.833332 $437.8300 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.835007 $339.0700 $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 -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.252055 $18.9100 $75.0100
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 9 11 0.065749 $4.9500 $75.2900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 0.027396 $2.0600 $75.2800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 0.021916 $1.6500 $75.2900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 0.027395 $1.5300 $55.7000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 6 13.413068 $684.7400 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 0.699086 $35.6900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 9 8.463491 $432.0600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 0.541171 $27.6200 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 19 13.576191 $693.0700 $51.0500
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Subtotal (Total Children Is Unduplicated) 60 84 40.199237 $2255.2500 $56.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.905556 $4528.0000 $5000.2400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 3.000000 $150.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.022222 $51.1100 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 44 307.571427 $15378.5800 $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 64 85 505.311903 $36099.4900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 13 14 73.357143 $4196.0400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 62 89 495.711904 $35413.6200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 7 41.999999 $2400.7300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.279452 $66.2800 $237.1600
SENS -V5264 EARMOLD 5 7 6.133332 $110.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 189 236 1616.109517 $115454.9400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 0.588889 $8.1700 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 314 466 4025.936930 $2012.9600 $0.5000
TRAV -TRAVS Travel by mile 10 18 119.900795 $53.3600 $0.4500
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Subtotal (Total Children Is Unduplicated) 508 1247 7560.235108 $228921.4200 $30.2800
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Total 1348 7612.267677 $231614.4900 $30.4300
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Number of Children (Unduplicated) With at Least One Authorization 532