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 4691 FSPSA's found of which 287 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
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Subtotal (Total Children Is Unduplicated) 14 23 145.107543 $116.2900 $0.8000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 5 280.611111 $13609.6400 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 5 3.222222 $150.8000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 5 3.208219 $383.7000 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 4 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 21 22 58.842242 $2942.1200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 7 4.155556 $311.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 28 32 22.808734 $1710.6800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 26 37 16.422143 $1231.6400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 15 16 7.822225 $434.1500 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 4 4.133334 $310.0100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.500000 $582.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 6 5.055556 $379.1700 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 11 14 5.282876 $792.4200 $150.0000
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) 102 163 444.530885 $23975.1700 $53.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 67.247184 $336235.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 50 51 58.403292 $2920.1600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.772222 $55.3000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.877778 $449.1700 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 128 175 474.049818 $23702.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 10 4.200001 $105.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 274 487 1191.534028 $59576.7000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 25 34 84.711109 $2117.7700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 10 34.025397 $2494.7400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 11 63.780954 $1594.5200 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 2.000000 $100.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 94 136 908.395133 $45419.8000 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 704 1537 13223.685736 $132236.8700 $10.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.044444 $484.7700 $237.1100
SENS -V5264 EARMOLD 3 5 9.883333 $177.9000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 2 7.071429 $505.1800 $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 673 2017 11405.490886 $5702.7400 $0.5000
TRAV -TRAVS Travel by mile 12 16 4706.818875 $2094.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 1012 4505 32255.991619 $616400.9100 $19.1100
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Total 4691 32845.630047 $640492.3700 $19.5000
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Number of Children (Unduplicated) With at Least One Authorization 1018