Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2580 FSPSA's found of which 16 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 26 5.897488 $286.0200 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 2.561644 $56.2300 $21.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.600000 $74.8800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.263014 $31.4500 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 4 5 0.871234 $43.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 53 53 28.187880 $1409.3900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 0.032874 $2.4800 $75.2900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.333333 $25.0000 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 0.054944 $3.0500 $55.5500
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 143 143 0.924990 $69.5300 $75.1700
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 19 19 0.101363 $7.6300 $75.2500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 176 177 1.080761 $60.1200 $55.6300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 0.095884 $7.2100 $75.1700
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 35.590584 $1816.9000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 11 1.619176 $82.6500 $51.0400
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 14 15 1.887671 $283.1600 $150.0000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 7 1.318950 $67.3300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 2.879757 $147.0200 $51.0500
SCREEN-T1023 SCREENING 8 9 2.128844 $106.4500 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 1.233104 $62.9500 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 0.109589 $5.4800 $50.0100
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Subtotal (Total Children Is Unduplicated) 302 541 88.784042 $4649.2900 $52.3700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 27 7.616667 $38083.5000 $5000.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 63 74 13.852485 $692.5700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.079452 $1.9900 $24.9800
CONIF -CONIF CONSULT, ITDS FACE TO FACE 104 213 339.118377 $16955.9900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 3.800000 $95.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.050000 $2.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.800000 $40.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 18 18 484.428571 $12110.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 191 1139.776193 $56988.7700 $50.0000
INTR -T1013 INTERPRETER 18 23 4.394065 $219.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 269 413 1888.249428 $18882.4600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 77 577.570352 $41261.6300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 84 90 611.438097 $43681.1000 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.263014 $62.3600 $237.1100
SENS -V5264 EARMOLD 2 2 0.986302 $17.7500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 103 117 825.112334 $58946.0200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 89 133 413.388667 $206.6900 $0.5000
TRAV -TRAVS Travel by mile 359 653 70096.247409 $31192.8400 $0.4500
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Subtotal (Total Children Is Unduplicated) 480 2038 76407.171413 $319441.6000 $4.1800
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Total 2579 76495.955455 $324090.9000 $4.2400
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Number of Children (Unduplicated) With at Least One Authorization 491