Summary Report for FSPSAs Ending During the Report Period Center: 06
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 1036 FSPSA's found of which 12 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
TCM -T1017TL TARGETED CASE MANAGEMENT 33 33 52.178336 $1930.6000 $37.0000
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Subtotal (Total Children Is Unduplicated) 33 33 52.178336 $1930.6000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 7 5.042922 $603.1300 $119.6000
EXIT -EXIT EXIT ASSESSMENT 3 3 0.271233 $13.5600 $49.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.164384 $8.3900 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.288889 $193.3400 $150.0000
SCREEN-T1023 SCREENING 4 4 3.266666 $163.3300 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.213698 $10.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 16 19 10.247792 $992.6600 $96.8700
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.200000 $10.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.900000 $95.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 64 65 4.855839 $242.8500 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.172222 $4.3100 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 20 42 60.697618 $3034.8900 $50.0000
CONIP -CONIP CONSULT, PHONE 8 16 20.900000 $522.5000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 32.000000 $800.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 45 46 284.562168 $7114.0500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 231 1394.485730 $69724.2800 $50.0000
INTR -T1013 INTERPRETER 19 19 33.518977 $1675.9600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 300 382 2176.933565 $21769.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 84.507141 $6037.1900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 8 30.521429 $1745.8200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 42 42 113.913097 $8137.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 22 22 69.620634 $3979.5100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.342466 $81.2100 $237.1400
SENS -V5264 EARMOLD 12 13 11.922222 $214.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 53 55 215.214283 $15374.9200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 54.357143 $754.4800 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
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Subtotal (Total Children Is Unduplicated) 384 984 4638.624534 $141342.8100 $30.4700
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Total 1036 4701.050662 $144266.0700 $30.6900
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Number of Children (Unduplicated) With at Least One Authorization 420