Summary Report for FSPSAs Initiated During the Report Period Center: 09
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
Eligibility Filter: Program Patients
With the filters selected there were 5460 FSPSA's found of which 152 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 2 2 0.866667 $16.6400 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.866667 $9.0300 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.866667 $7.5800 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.866667 $18.9300 $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
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.361111 $16.9000 $46.8000
EXIT -EXIT EXIT ASSESSMENT 21 21 9.261263 $463.0700 $50.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 2 3.066666 $153.3300 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 14 15 80.307936 $4015.4000 $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
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.427778 $21.8400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.088889 $4.5400 $51.0600
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Subtotal (Total Children Is Unduplicated) 41 55 99.013645 $4835.3800 $48.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.673015 $13365.0000 $4999.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 11.714286 $585.7200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.361111 $18.0600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 189 239 19.089492 $954.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 34 38 2.416929 $60.4200 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 234 543 1208.970089 $60448.3600 $50.0000
CONIP -CONIP CONSULT, PHONE 12 16 4.974810 $124.3700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1113 1480 10589.683298 $529484.8900 $50.0000
INTR -T1013 INTERPRETER 30 31 1146.225399 $57311.2700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 201 278 2024.647184 $144640.9100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 281 397 2875.490483 $205425.2100 $71.4400
SENS -V5264 EARMOLD 1 1 0.361111 $6.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 558 764 6071.855092 $433773.8300 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1154 1612 12984.623150 $6492.2900 $0.5000
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Subtotal (Total Children Is Unduplicated) 1661 5404 36943.085449 $1452691.2500 $39.3200
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Total 5459 37042.099094 $1457526.6300 $39.3500
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Number of Children (Unduplicated) With at Least One Authorization 1661