Summary Report for FSPSAs Ending During the Report Period Center: 53
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 1514 FSPSA's found of which 19 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 1 1 0.142857 $5.2900 $37.0100
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 5 13.684525 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 0.714285 $26.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 8 14.541667 $31.7200 $2.1800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 118.011111 $5723.5400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.355556 $7.8100 $21.9500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.505556 $23.6600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.955556 $114.2900 $119.6100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 3 3 25.377778 $1268.8900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.483333 $111.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 8 3.494444 $262.0800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 26 36 166.016670 $12451.2800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 25 14.966664 $1122.4800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 27 36 17.116669 $949.9900 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 3 3.116667 $233.7500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 37 38 63.155173 $3505.1200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 16.505479 $1237.9100 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.177778 $9.0800 $51.0600
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Subtotal (Total Children Is Unduplicated) 101 170 433.238434 $27121.1200 $62.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 1.880518 $9402.5000 $4999.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 22 22 13.848412 $692.4200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.327778 $23.4700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.400000 $95.6800 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 43 47 115.161112 $5758.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 0.755556 $18.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 158 195.849281 $9792.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 8 5.605556 $140.1400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 5.228571 $383.3600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 53.623810 $1340.5900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 358 421 2351.432943 $117571.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 338 503 2008.005692 $20080.0600 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.450000 $29.2500 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.200000 $284.5400 $237.1200
SENS -V5264 EARMOLD 3 3 2.211111 $39.8000 $18.0000
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 89 146 747.286506 $373.6400 $0.5000
TRAV -TRAVS Travel by mile 2 2 1525.719842 $678.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 411 1336 7028.986688 $166705.4600 $23.7200
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Total 1514 7476.766789 $193858.2900 $25.9300
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Number of Children (Unduplicated) With at Least One Authorization 424