Summary Report for FSPSAs Ending During the Report Period Center: 09
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
Eligibility Filter: Program Patients
With the filters selected there were 2774 FSPSA's found of which 87 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.505556 $7.5500 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.505556 $9.7100 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.505556 $5.2700 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.505556 $4.4200 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.505556 $11.0400 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.505556 $32.9300 $65.1500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.505556 $11.5800 $22.9000
EXIT -EXIT EXIT ASSESSMENT 21 21 9.261263 $463.0700 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 2.533333 $126.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 26.957144 $1347.8600 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.216666 $11.0600 $51.0300
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.300000 $45.0000 $150.0000
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Subtotal (Total Children Is Unduplicated) 29 36 42.807298 $2076.1500 $48.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.161904 $10809.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 11.714286 $585.7200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 169 218 12.578380 $628.8700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 32 35 1.700263 $42.5000 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 144 266 374.181961 $18709.0100 $50.0000
CONIP -CONIP CONSULT, PHONE 11 14 2.108144 $52.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 593 655 3705.199224 $185260.0400 $50.0000
INTR -T1013 INTERPRETER 21 22 705.939684 $35296.9800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 113 123 771.650366 $55126.6800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 149 169 920.728588 $65776.8200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 282 320 2048.459100 $146341.9100 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 643 912 5109.451753 $2554.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 940 2737 13665.873653 $521185.4400 $38.1400
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Total 2773 13708.680951 $523261.5900 $38.1700
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Number of Children (Unduplicated) With at Least One Authorization 940