Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1103 FSPSA's found of which 6 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 1 1 0.400000 $14.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.400000 $14.8000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.233333 $23.2700 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.233333 $19.5400 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.233333 $48.7800 $21.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.333333 $59.5700 $25.5300
EXIT -EXIT EXIT ASSESSMENT 1 1 0.344444 $17.2200 $49.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 4.188432 $213.8300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 1.423211 $72.6500 $51.0500
SCREEN-T1023 SCREENING 22 23 6.672985 $333.6500 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 6.104869 $311.6500 $51.0500
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Subtotal (Total Children Is Unduplicated) 50 58 27.767273 $1100.1500 $39.6200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.233333 $111.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 69 21.937753 $1096.8900 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 129 290 496.484806 $24824.2800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 141 150 679.618670 $33980.8900 $50.0000
INTR -T1013 INTERPRETER 3 4 11.852382 $592.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 2 2.133334 $21.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 36 116.277381 $8306.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 9 9 47.375000 $2709.8400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 31 31 116.646826 $8333.2500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.142857 $293.9700 $57.1600
SENS -V5264 EARMOLD 1 1 0.744444 $13.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 90 100 484.248813 $34594.7100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 170 320 2499.917498 $1249.9600 $0.5000
TRAV -TRAVS Travel by mile 20 30 258.249210 $114.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 253 1044 4742.862307 $116244.5900 $24.5100
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Total 1103 4771.029580 $117359.5400 $24.6000
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Number of Children (Unduplicated) With at Least One Authorization 267