Summary Report for FSPSAs Ending During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 17928 FSPSA's found of which 1338 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
CASE -CASE NON-TCM CASE MANAGEMENT 3 6 5.311111 $196.5100 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 14 43.951588 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 66 66 196.433890 $7268.0500 $37.0000
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Subtotal (Total Children Is Unduplicated) 80 86 245.696589 $7464.5700 $30.3800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 36 37 78.936984 $3828.4400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.988889 $46.5700 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 18 18 96.433335 $1439.7500 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 11 11 93.350001 $1792.3200 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 19 96.521006 $1005.7500 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 91.000000 $1997.4500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 22 23 100.207384 $876.8200 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 91.205556 $735.1200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 20 96.614157 $2110.0600 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 91.087671 $2632.4300 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 10 10 96.270635 $6271.0700 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 19 20 5.625268 $128.8200 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 94.472222 $2411.8800 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 61.739117 $2889.3900 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.776908 $810.5300 $119.6000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 0.361872 $45.2400 $125.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 16 24 28.145357 $1407.2600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 338 374 480.915335 $24045.7700 $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 3 2.048554 $153.6400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 1.483257 $111.2500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 11 3.171459 $237.8600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 12 4.695281 $260.5900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 51 53 25.883702 $1941.3200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 18 19 17.693605 $1327.0400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 4.772601 $357.9500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 93 94 49.285761 $2735.4000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 32 22.205349 $1665.4100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 19 21.127647 $1078.5700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 45 46 57.985743 $2960.1700 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 64 69 35.919831 $5388.0300 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 30 31 10.146450 $517.9800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 24 24 74.835464 $3820.3600 $51.0500
SCREEN-T1023 SCREENING 14 14 8.878157 $443.9100 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.427778 $6.6700 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 121 125 91.142487 $4652.8200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.487671 $24.9000 $51.0500
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Subtotal (Total Children Is Unduplicated) 819 1151 2043.136786 $82175.0700 $40.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 20 10.888617 $54443.5000 $5000.0400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.666667 $83.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 16 25.504283 $1275.2100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.488889 $116.9400 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 778 897 286.816058 $14340.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 9 0.525001 $13.1300 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 1093 1828 2535.272860 $126763.7400 $50.0000
CONIP -CONIP CONSULT, PHONE 34 63 84.497224 $2112.4400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.444444 $32.5800 $73.3100
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 17 121.242859 $3031.0700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 30.946032 $1547.3000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 24.777777 $1238.8900 $50.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 0.010959 $0.5500 $50.1900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1250 1371 8338.953472 $416947.7000 $50.0000
INTR -T1013 INTERPRETER 128 155 1152.389415 $57619.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3936 5992 23713.592844 $237135.8800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 250 265 1661.527415 $118699.5500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 20 20 94.057142 $5380.0700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 258 282 1597.804768 $114147.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 57.892857 $3309.1600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 72.845009 $17273.0300 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.241096 $114.3400 $474.2500
SENS -V5264 EARMOLD 11 11 234.042857 $4212.7700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 706 750 4436.475780 $316941.9500 $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 20 20 269.357144 $3738.6800 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1954 3019 15175.159139 $7587.5700 $0.5000
TRAV -TRAVS Travel by mile 1251 1928 48790.657690 $21711.8500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7005 16691 108721.506869 $1530014.9400 $14.0700
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Total 17928 111010.340244 $1619654.5800 $14.5900
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Number of Children (Unduplicated) With at Least One Authorization 7260