Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 5888 FSPSA's found of which 13 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 15 15 6.530370 $241.6100 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 15 15 6.530370 $241.6100 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 10 10 6.237302 $406.3000 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.022222 $47.8400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.252055 $30.1500 $119.6200
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.488889 $36.6700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 3.499999 $194.2600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 16 4.988887 $374.1900 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 33 38 46.609980 $2379.4400 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 122 131 96.010503 $4901.3000 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 74 86 87.310967 $4457.2200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 75 78 45.194439 $2307.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 276 313 277.391747 $14160.8300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 15 15 25.608731 $1307.3300 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 494 705 598.615721 $30902.6800 $51.6200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.322222 $77.0700 $239.1800
CONIF -CONIF CONSULT, FACE TO FACE 498 798 775.293623 $38764.6100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 75 76 656.571421 $16414.3100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 886 1040 9396.766599 $469839.0100 $50.0000
INTR -T1013 INTERPRETER 1 1 1.285714 $64.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1024 2515 12069.357391 $120693.6500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 123 137 865.754292 $61849.5300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 64.785714 $3705.7400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 141 167 1253.400793 $89543.0400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 22 23 207.714284 $11872.9700 $57.1600
SENS -V5264 EARMOLD 1 1 1.022222 $18.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 263 297 2260.447619 $161486.5500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 10.000000 $572.0000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 19 19 133.329366 $1850.6100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 28 34 854.608726 $427.3000 $0.5000
TRAV -TRAVS Travel by mile 31 47 465.079365 $206.9600 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1288 5168 29015.739351 $977386.0200 $33.6800
-------------------------------------------------------------------------------------------------------------------------------------
Total 5888 29620.885442 $1008530.3100 $34.0500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1324