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: 07-01-15 and 06-30-16 Date of Report: 08-06-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 7582 FSPSA's found of which 372 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 2 4 3.142857 $116.2900 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 13 19 141.964686 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 25.714285 $951.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 27 170.821828 $1067.7200 $6.2500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 5 280.611111 $13609.6400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 5.716667 $125.4800 $21.9500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.150000 $3.2800 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.994444 $64.7800 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.022222 $39.2200 $38.3700
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 8 4.755556 $222.5600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 10 6.030441 $721.2400 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 4 6 12.388889 $619.4500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 22 24 61.842242 $3092.1200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 5 10.266668 $770.0100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 28 36 106.699998 $8002.4900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 87 132 778.476193 $58385.7400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.133334 $460.0100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 76 180 280.124650 $21009.3000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 76 97 165.390479 $9179.1900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 0.027778 $2.0900 $75.0600
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 20 20.138812 $1510.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 4.011111 $300.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 108 111 197.110651 $10939.6400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 70 77 107.950389 $8096.2900 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 17 20 9.779223 $1466.8700 $150.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.177778 $9.0800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.733333 $37.4400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 12.466667 $636.4300 $51.0500
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Subtotal (Total Children Is Unduplicated) 388 754 2072.998636 $139303.5400 $67.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 17 74.465829 $372329.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 56 57 65.175514 $3258.7700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.216666 $87.1200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 4.795815 $1147.1800 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 131 178 477.549818 $23877.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 10 4.200001 $105.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 275 492 1209.667361 $60483.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 25 34 84.711109 $2117.7700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 14 44.092064 $3232.8300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 51 405.033337 $10125.8300 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 36 36 65.700000 $3285.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 924 2267 21056.718440 $1052836.3200 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 704 1543 13269.215893 $132692.1700 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.966667 $62.8400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 4 4.961110 $1176.3500 $237.1100
SENS -V5264 EARMOLD 6 13 15.461111 $278.3000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 6 26.857143 $1918.6800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.000000 $27.7600 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 678 2052 11617.673427 $5808.8300 $0.5000
TRAV -TRAVS Travel by mile 12 16 4706.818875 $2094.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 1029 6801 53145.280180 $1677345.1500 $31.5600
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Total 7582 55389.100644 $1817716.4100 $32.8200
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Number of Children (Unduplicated) With at Least One Authorization 1050