Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 2304 FSPSA's found of which 9 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 10 11 987.307936 $36530.3900 $37.0000
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Subtotal (Total Children Is Unduplicated) 10 11 987.307936 $36530.3900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 4 1.947641 $91.7200 $47.0900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 13 2.268493 $19.8500 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 14 2.350685 $51.3500 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.175342 $11.4200 $65.1200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 2.241096 $51.3300 $22.9000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 5 3.304566 $154.6500 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 4 3.170319 $379.1700 $119.6000
EXIT -EXIT EXIT ASSESSMENT 32 36 2.007839 $100.3800 $49.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 13.142858 $985.7100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 0.016438 $1.2300 $74.8300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 16 0.057536 $3.1700 $55.0700
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 13 0.041098 $3.0500 $74.2700
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 0.464917 $23.7300 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 0.221917 $33.2900 $149.9900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.428571 $21.8800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 13.762112 $702.5600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.432115 $22.0600 $51.0500
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Subtotal (Total Children Is Unduplicated) 82 144 46.033543 $2656.5400 $57.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071233 $356.0000 $4997.6800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 5.994216 $299.7100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.005556 $0.4000 $72.1700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.117808 $28.1800 $239.1800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 59 73 56.342282 $2817.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 112 215 705.814288 $35290.7500 $50.0000
CONIP -CONIP CONSULT, PHONE 3 5 14.295237 $357.3800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.285714 $82.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 813 1036 8986.903684 $449345.7000 $50.0000
INTR -T1013 INTERPRETER 6 6 63.434051 $3171.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 54 58 505.072145 $5050.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 64.285714 $4592.5800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $187.9400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 9 10 75.933338 $5424.6900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 7.285714 $416.4500 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.642542 $152.3700 $237.1400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.082192 $38.9800 $474.2900
SENS -V5264 EARMOLD 2 3 3.153881 $56.7700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 51 410.988097 $29361.0200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 2 11.285714 $156.6500 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 526 644 5592.837773 $2796.4100 $0.5000
TRAV -TRAVS Travel by mile 21 24 148.719765 $66.1800 $0.4400
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Subtotal (Total Children Is Unduplicated) 845 2149 16659.842214 $540050.0000 $32.4200
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Total 2304 17693.183693 $579236.9300 $32.7400
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Number of Children (Unduplicated) With at Least One Authorization 861