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 4177 FSPSA's found of which 12 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 7 7 3.506666 $129.7400 $37.0000
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Subtotal (Total Children Is Unduplicated) 7 7 3.506666 $129.7400 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 5.292857 $344.7800 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.511111 $23.9200 $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 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 0.285714 $15.8600 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 0.285714 $21.4400 $75.0200
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 20 33.049207 $1687.1700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 50 52 49.003169 $2501.5900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 36 41 52.583354 $2684.3800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 29 30 20.819839 $1062.8400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 142 160 149.298212 $7621.6700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 12 12 24.147620 $1232.7400 $51.0500
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Subtotal (Total Children Is Unduplicated) 238 329 337.528852 $17376.5500 $51.4800
EI Services, Class # 03
CONIF -CONIF CONSULT, FACE TO FACE 497 794 773.471401 $38673.5000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.857143 $221.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 226 257 2300.249986 $115012.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1012 2467 11799.751836 $117997.5900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 33 271.535715 $19398.5200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 6 42.000000 $2402.4000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 44 52 457.407935 $32677.2500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 13 13 119.999998 $6859.2100 $57.1600
SENS -V5264 EARMOLD 1 1 1.022222 $18.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 121 1009.697616 $72132.8500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 110.467460 $1533.2900 $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
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Subtotal (Total Children Is Unduplicated) 1127 3841 18217.577974 $407757.4800 $22.3800
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Total 4177 18558.613492 $425263.7600 $22.9100
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Number of Children (Unduplicated) With at Least One Authorization 1166