Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 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 7926 FSPSA's found of which 153 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 17 25 187.168654 $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) 19 33 216.025796 $1067.7200 $4.9400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 6 281.611111 $13658.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.111111 $52.3200 $47.0900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.277778 $13.3100 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 43 46 26.823016 $588.7700 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.950000 $192.1600 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.022222 $39.2200 $38.3700
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 11 9.588890 $448.7700 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 12 10.274886 $1228.8800 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 5 12.000000 $600.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 22 24 61.842242 $3092.1200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 9 9 16.561113 $1242.1000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 28 36 107.211112 $8040.8400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 91 138 766.332804 $57474.9900 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 12.055556 $904.1700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 70 136 269.749695 $20231.2300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 123 168 256.801061 $14252.5000 $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 7 16 14.561034 $1092.0800 $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 109 112 198.910651 $11039.5400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 69 76 108.742169 $8155.6700 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 11 13 6.293987 $944.0900 $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) 416 830 2183.137105 $144276.7400 $66.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 25 13.760273 $68801.0000 $4999.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.238888 $111.9400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 111 116 110.169220 $5508.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 9.326984 $667.9000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 18 18 8.504546 $2034.3200 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 137 189 746.455373 $37322.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 11 5.055557 $126.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 411 770 1780.834831 $89041.7900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 47 64 132.211111 $3305.2800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 20 23 77.630157 $5691.8400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 42 54 452.919048 $11322.9800 $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 1056 2282 22438.655003 $1121933.0100 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 954 2368 19527.392034 $195273.9600 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.238890 $210.5400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 5 6 7.938888 $1882.4500 $237.1200
SENS -V5264 EARMOLD 10 14 21.061111 $379.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 7.642857 $546.0100 $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 442 1059 6550.928347 $3275.4600 $0.5000
TRAV -TRAVS Travel by mile 12 13 4687.466494 $2085.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 1131 7063 56659.129612 $1553233.8800 $27.4100
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Total 7926 59058.292513 $1698578.3400 $28.7600
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Number of Children (Unduplicated) With at Least One Authorization 1141