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 4900 FSPSA's found of which 117 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
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Subtotal (Total Children Is Unduplicated) 18 29 190.311511 $116.2900 $0.6100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 6 281.611111 $13658.1400 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.277778 $13.3100 $10.4200
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 2.755556 $128.9600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 4 2.980442 $356.4700 $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 3.972222 $297.9200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 27 33 19.722223 $1479.1700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.488889 $36.6700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 18 6.266588 $469.9800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 31 14.705557 $816.1700 $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 8 10 2.682876 $402.4200 $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) 88 156 437.461041 $23009.6700 $52.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 8 2.902739 $14513.0000 $4999.7600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.238888 $111.9400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 99 104 98.408902 $4920.4400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 8.676984 $621.3500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.150001 $753.5000 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 134 186 742.955373 $37147.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 11 5.055557 $126.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 411 765 1762.701498 $88135.1300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 47 64 132.211111 $3305.2800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 28.211110 $2068.4300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 9 54.504762 $1362.6200 $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 87 125 920.450793 $46022.5800 $50.0000
INTR -T1013 INTERPRETER 1 1 8.000000 $400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 954 2360 19473.195210 $194731.9900 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.705556 $45.8600 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.044444 $484.7700 $237.1100
SENS -V5264 EARMOLD 2 3 9.600000 $172.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 0.500000 $35.7200 $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 439 1042 6488.845806 $3244.4200 $0.5000
TRAV -TRAVS Travel by mile 12 13 4687.466494 $2085.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 1111 4715 34435.825228 $400417.6900 $11.6300
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Total 4900 35063.597780 $423543.6500 $12.0800
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Number of Children (Unduplicated) With at Least One Authorization 1115