Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2530 FSPSA's found of which 8 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.928571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 21 21 146.927778 $5436.3300 $37.0000
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Subtotal (Total Children Is Unduplicated) 22 22 147.856349 $5436.3300 $36.7700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 4.915297 $238.3900 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 91.000000 $1358.6300 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 91.000000 $1747.2000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 91.000000 $948.2200 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 91.000000 $1997.4500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 91.000000 $796.2500 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 91.000000 $1987.4400 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 91.000000 $2629.9000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 91.000000 $5927.7400 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 91.000000 $2323.2300 $25.5300
EVAL -96111 DEVELOPMENTAL EVALUATION 5 8 13.000000 $650.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 140 158 298.576905 $14928.8400 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 5.519177 $306.3200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 3.500000 $262.5000 $75.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 3 0.389041 $58.3700 $150.0200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 68.000000 $3471.4000 $51.0500
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Subtotal (Total Children Is Unduplicated) 162 199 1305.905899 $40515.7500 $31.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.127778 $639.0000 $5000.8600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 5.263014 $263.1500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 162 176 115.822285 $5791.0800 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 54 88 136.676109 $6833.7800 $50.0000
CONIP -CONIP CONSULT, PHONE 1 2 0.933334 $23.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.214286 $55.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 33 142.080299 $7104.0100 $50.0000
INTR -T1013 INTERPRETER 52 72 354.695434 $17734.7700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 546 771 3275.389650 $32753.8700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 7 22.938095 $1638.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 8 34.500001 $2464.6700 $71.4400
SENS -V5264 EARMOLD 1 1 91.000000 $1638.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 13 78.190477 $5585.9200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 58.571429 $812.9700 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 89 112 533.123802 $266.5600 $0.5000
TRAV -TRAVS Travel by mile 692 1019 5898.133566 $2624.6700 $0.4400
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Subtotal (Total Children Is Unduplicated) 778 2309 10749.659559 $86229.8300 $8.0200
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Total 2530 12203.421807 $132181.9000 $10.8300
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Number of Children (Unduplicated) With at Least One Authorization 800