Summary Report for FSPSAs Initiated During the Report Period Center: 06
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 1347 FSPSA's found of which 5 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 39 39 68.062783 $2518.3300 $37.0000
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Subtotal (Total Children Is Unduplicated) 39 39 68.062783 $2518.3300 $37.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 4 4 0.356165 $17.8100 $49.9900
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 2 2 1.288889 $193.3400 $150.0000
SCREEN-T1023 SCREENING 13 14 9.550000 $477.5000 $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) 20 22 11.408752 $699.5500 $61.3200
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 5.039682 $251.9900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 4.573016 $228.6600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.065753 $15.7400 $239.3700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 97 101 23.842120 $1192.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 0.705555 $17.6400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 49 114 164.114288 $8205.7400 $50.0000
CONIP -CONIP CONSULT, PHONE 11 29 40.633333 $1015.8300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 0.876208 $21.9100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 20 121.590480 $6079.5400 $50.0000
INTR -T1013 INTERPRETER 24 26 126.833527 $6341.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 601 921 6298.300196 $62983.0800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 12 44.952380 $3211.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 4 12.100000 $692.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 10 32.997620 $2357.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 16.928572 $967.6300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 3.894064 $253.1200 $65.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.131507 $31.1800 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.128767 $61.0800 $474.3600
SENS -V5264 EARMOLD 1 1 0.688889 $12.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 14 60.642858 $4332.3400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 53.214286 $738.6100 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
TRAV -TRAVS Travel by mile 1 1 0.133333 $0.0600 $0.4400
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Subtotal (Total Children Is Unduplicated) 622 1286 7060.386434 $99035.2500 $14.0300
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Total 1347 7139.857969 $102253.1300 $14.3200
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Number of Children (Unduplicated) With at Least One Authorization 667