Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 913 FSPSA's found
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 11 13 7.488888 $277.0900 $37.0000
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Subtotal (Total Children Is Unduplicated) 11 13 7.488888 $277.0900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.301674 $155.6800 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 4 0.175342 $8.7700 $50.0200
EXIT -EXIT EXIT ASSESSMENT 4 4 0.079453 $3.9700 $49.9700
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.010958 $0.6100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 6 0.032874 $2.4800 $75.2900
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 0.010958 $0.8300 $75.2900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 9.035290 $461.2500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 0.599086 $30.5800 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 7 3.751587 $191.5200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.387747 $19.7900 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 1.866667 $95.3000 $51.0500
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Subtotal (Total Children Is Unduplicated) 34 46 17.251636 $970.7800 $56.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.450000 $2250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.466667 $73.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.022222 $51.1100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 28 11.543455 $577.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 7 5.383334 $134.5900 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 49 98 112.051629 $5602.5800 $50.0000
CONIP -CONIP CONSULT, PHONE 34 72 123.449602 $3086.2400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 58.285714 $2914.2900 $50.0000
INTR -T1013 INTERPRETER 2 2 2.972146 $148.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 3 39.428571 $394.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 54 329.107143 $23511.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 9 52.642857 $3011.1800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 43 61 345.033336 $24649.1400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 4 31.428571 $1796.4600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.279452 $66.2800 $237.1600
SENS -V5264 EARMOLD 2 3 3.066666 $55.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 104 133 888.145234 $63449.1400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 0.588889 $8.1700 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 241 355 3013.535352 $1506.7600 $0.5000
TRAV -TRAVS Travel by mile 7 13 92.615080 $41.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 372 854 5112.495920 $133327.1600 $26.0800
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Total 913 5137.236444 $134575.0300 $26.2000
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Number of Children (Unduplicated) With at Least One Authorization 387