Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 7055 FSPSA's found of which 13 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 83 92 203.267454 $7520.8800 $37.0000
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Subtotal (Total Children Is Unduplicated) 83 93 204.196025 $7520.8800 $36.8300
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $205.2600 $102.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 18 17.357491 $841.8300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 0.411111 $19.3600 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 91.000000 $1358.6300 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 104.965079 $2015.3300 $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) 2 2 92.000000 $805.0000 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 92.000000 $2009.2800 $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) 2 2 91.488889 $2335.7100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.533333 $118.5600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.066666 $366.7700 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 5 9 16.000000 $800.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 141 159 298.626220 $14931.3100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 9.513698 $713.5300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 7.300782 $547.5600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 4.508220 $338.1200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 16 14.311740 $1073.3900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 11 12 18.000000 $999.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 126 126 158.563139 $11892.2600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 59 59 72.240316 $5418.0200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 33 34 30.065754 $2254.9300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 159 160 288.313697 $16001.4200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 81 96 114.579450 $8593.4600 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.433333 $22.1200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 3.000000 $153.1500 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 3 0.389041 $58.3700 $150.0200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 162.085921 $8274.4900 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.022222 $15.9500 $15.6000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0600 $51.0800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 123.309210 $6294.9400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 62.000000 $3165.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 447 766 2348.736193 $104492.2100 $44.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 13 16.688520 $83444.0000 $5000.0800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 11 55.333377 $2766.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 164 180 123.291875 $6164.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 1.133334 $28.3400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 112 231 618.306272 $30915.3000 $50.0000
CONIP -CONIP CONSULT, PHONE 3 5 8.433335 $210.8400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 97.500000 $2437.5100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1021 1316 9772.497306 $488625.3700 $50.0000
INTR -T1013 INTERPRETER 79 115 802.924004 $40146.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1067 1768 11950.942838 $119509.5400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 34 205.576186 $14686.3900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 101 147 1061.167156 $75809.8000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 21.000000 $1200.3600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.521156 $163.8700 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 1.011111 $119.8800 $118.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.252055 $59.7800 $237.1600
SENS -V5264 EARMOLD 5 6 95.226484 $1714.0800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 139 176 1448.328558 $103468.7200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 117.071430 $1624.9500 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 124 150 975.536499 $487.7700 $0.5000
TRAV -TRAVS Travel by mile 1108 2015 21695.758540 $9654.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 1206 6196 49070.500036 $983238.5600 $20.0400
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Total 7055 51623.432254 $1095251.6500 $21.2200
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Number of Children (Unduplicated) With at Least One Authorization 1284