Summary Report for FSPSAs Initiated During the Report Period Statewide
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 66098 FSPSA's found of which 2716 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 27 41 151.543653 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 265 286 1444.795112 $53457.4000 $37.0000
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Subtotal (Total Children Is Unduplicated) 293 333 1601.649876 $53653.9100 $33.5000
Screening, Eval, and Assessment, Class # 02
AACIO -92597GO AAC INITIAL EVAL BY LICENSED OT 1 1 0.005479 $0.5600 $103.0300
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 2.433333 $249.7300 $102.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 121 146 229.428886 $11127.3100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 24 26 9.701978 $456.8700 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 291 293 222.492759 $3321.8000 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 264 269 223.109502 $4283.7000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 294 298 229.819243 $2394.7100 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 20 100.797721 $2212.5100 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 310 314 232.828224 $2037.2400 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 5 5 92.250000 $743.5400 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 314 322 241.091998 $5265.4300 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 94.352055 $2726.7800 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 159 161 162.087984 $10558.4000 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.511111 $19.6100 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 296 299 129.152425 $2957.5800 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 14 16 101.381658 $2588.2700 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 48 52 108.194607 $5063.5000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 69 78 53.949981 $6452.4600 $119.6000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 0.301599 $37.7000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 27 36 36.136530 $1806.8200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 452 493 565.023060 $28251.1600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 1.302588 $97.7000 $75.0000
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 40 44 91.461485 $6859.6100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 59 64 401.500930 $30112.5600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 8.901142 $667.5800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 68 101 167.434713 $12557.5700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 71 75 62.929116 $3492.5500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 489 494 290.778036 $21808.8500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 190 193 112.279640 $8421.1600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 110 112 41.972579 $3148.0300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 435 442 428.028766 $23755.7200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 245 272 178.618617 $13396.5400 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 3 3.166666 $158.3300 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 14 15 80.307936 $4015.4000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 98 112 150.867761 $7701.7900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 424 443 283.032077 $14448.8100 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 92 101 76.790933 $11518.7100 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 158 179 124.012118 $6330.8100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 282 291 400.540534 $20447.5900 $51.0500
SCREEN-T1023 SCREENING 75 78 34.188508 $1709.4300 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 6 6 2.862937 $44.6600 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.200000 $10.2100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.590563 $30.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 693 760 773.639763 $39494.3300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 30 30 113.185921 $5778.1500 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 3 3 0.695891 $34.8000 $50.0100
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Subtotal (Total Children Is Unduplicated) 3468 6677 6677.194115 $329240.9800 $49.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 152 178 232.134694 $1160679.0000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 20 21 30.433799 $1521.6900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 117 122 170.837017 $8541.8600 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.030159 $288.6000 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 14 14 19.096727 $1367.5100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 1.841172 $440.4400 $239.2200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1191 1446 658.933071 $32946.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 58 72 28.226734 $705.6800 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 3199 6707 12550.732472 $627537.3800 $50.0000
CONIP -CONIP CONSULT, PHONE 105 198 287.062512 $7176.5800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 10.082540 $739.2500 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 110.714287 $2767.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 428 493 6325.186340 $158129.7800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 6 264.946032 $13247.3000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 15 18 84.197618 $4209.8800 $50.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 3 3 2.213699 $110.6900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11231 14303 111830.476306 $5591530.5300 $50.0000
INTR -T1013 INTERPRETER 198 247 2398.629748 $119931.5600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 8000 14097 77285.886975 $772859.6100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1757 2196 15927.701230 $1137875.5900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 158 179 1129.717462 $64619.8400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 2161 2766 19160.600154 $1368833.8000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 151 169 926.236906 $52943.7100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 15 15 6.941247 $451.1800 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 6 6 2.133104 $252.8900 $118.5500
SENS -V5050 IN EAR MONAURAL HEARING AID 29 30 71.700840 $17001.7900 $237.1200
SENS -V5060 BEHIND EAR HEARING AID
2 2 0.298174 $70.7100 $237.1400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 10 10 2.046652 $970.6700 $474.2700
SENS -V5264 EARMOLD 122 143 376.745641 $6781.4200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3959 4938 37245.855330 $2660846.3400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 48.071429 $2749.6900 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 113 116 970.462697 $13470.0200 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 4416 6695 49403.238313 $24701.5600 $0.5000
TRAV -TRAVS Travel by mile 2037 3870 184522.695770 $82112.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 15768 59088 522090.106851 $13938413.7500 $26.7000
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Total 66098 530368.950842 $14321308.6400 $27.0000
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Number of Children (Unduplicated) With at Least One Authorization 16235