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 777 FSPSA's found of which 46 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.361111 $6.9300 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.361111 $3.7600 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.361111 $3.1600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.361111 $7.8900 $21.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.361111 $16.9000 $46.8000
EXIT -EXIT EXIT ASSESSMENT 14 14 5.483485 $274.1800 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.766667 $38.3400 $50.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.300000 $45.0000 $150.0000
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Subtotal (Total Children Is Unduplicated) 17 21 8.355707 $396.1600 $47.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.161904 $10809.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.361111 $18.0600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 45 64 1.335568 $66.7800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 25 37 29.866119 $1493.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 164 182 1247.347624 $62367.4200 $50.0000
INTR -T1013 INTERPRETER 29 30 1146.214288 $57310.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 57 442.538097 $31614.9500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 60 63 441.509529 $31541.4600 $71.4400
SENS -V5264 EARMOLD 1 1 0.361111 $6.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 146 171 1263.795233 $90285.6200 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 120 146 774.532347 $387.2600 $0.5000
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Subtotal (Total Children Is Unduplicated) 419 755 5350.028487 $285901.6900 $53.4400
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Total 776 5358.384194 $286297.8400 $53.4300
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Number of Children (Unduplicated) With at Least One Authorization 426