Summary Report for FSPSAs Ending During the Report Period Center: 10
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 2573 FSPSA's found of which 603 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 6 6 2.722223 $100.7300 $37.0000
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Subtotal (Total Children Is Unduplicated) 6 6 2.722223 $100.7300 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 80 80 25.779840 $384.9000 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 50 50 15.479839 $297.2300 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 80 81 26.102062 $271.9900 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 78 79 25.774285 $225.5300 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 0.738889 $5.9600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 79 81 26.218728 $572.6300 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 38 38 12.179838 $793.4300 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 79 79 25.663173 $587.7000 $22.9000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 12 6.105557 $311.7000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 6 2.088888 $106.6300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 24 27 17.382542 $887.3900 $51.0500
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Subtotal (Total Children Is Unduplicated) 122 536 183.513641 $4445.0900 $24.2200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 10 1.511110 $75.5500 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 47 83 49.104766 $2455.2600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 476 579 3661.148797 $183057.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 512 978 460.775909 $4607.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 86 89 350.601593 $25047.0100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 150 154 508.083339 $36297.5400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.071429 $4.0800 $57.1400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 132 137 631.107141 $45086.3300 $71.4400
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Subtotal (Total Children Is Unduplicated) 664 2031 5662.404084 $296631.0200 $52.3900
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Total 2573 5848.639948 $301176.8400 $51.5000
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Number of Children (Unduplicated) With at Least One Authorization 691