Summary Report for FSPSAs Ending During the Report Period Center: 07
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 567 FSPSA's found of which 7 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
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.555556 $26.1600 $47.0900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.128767 $1.1300 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.128767 $2.8100 $21.8500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.128767 $2.9500 $22.9100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.136986 $6.4100 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.136986 $16.3900 $119.6100
EXIT -EXIT EXIT ASSESSMENT 29 33 1.717428 $85.8600 $49.9900
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 0.221917 $33.2900 $149.9900
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.866667 $44.2500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.087671 $4.4800 $51.0700
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Subtotal (Total Children Is Unduplicated) 34 44 4.109512 $223.7200 $54.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071233 $356.0000 $4997.6800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.888889 $44.4500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 38 26.577205 $1328.8800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 26 42 100.799999 $5040.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 36 241.084672 $12054.2500 $50.0000
INTR -T1013 INTERPRETER 3 3 12.005480 $600.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 33 35 214.719766 $2147.2000 $10.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.571429 $326.5800 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.136986 $32.4900 $237.1400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 55.428571 $3959.8200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 287 350 2278.885394 $1139.4400 $0.5000
TRAV -TRAVS Travel by mile 6 7 28.005479 $12.4600 $0.4400
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Subtotal (Total Children Is Unduplicated) 341 523 2963.180659 $27041.9600 $9.1300
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Total 567 2967.290171 $27265.6800 $9.1900
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Number of Children (Unduplicated) With at Least One Authorization 359