Summary Report for FSPSAs Ending During the Report Period Center: 10
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 3550 FSPSA's found of which 840 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 7 7 3.111112 $115.1100 $37.0000
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Subtotal (Total Children Is Unduplicated) 7 7 3.111112 $115.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 110 110 35.290949 $526.9000 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 70 70 20.785395 $399.0900 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 110 111 35.613171 $371.0900 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 107 108 35.057616 $306.7600 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 0.738889 $5.9600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 109 112 35.957615 $785.3200 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 53 53 16.513171 $1075.7000 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 109 110 35.185393 $805.7600 $22.9000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 21 22 10.494446 $535.7500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 8 3.011110 $153.7100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 33 38 22.749209 $1161.3600 $51.0500
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Subtotal (Total Children Is Unduplicated) 180 745 251.396964 $6127.4100 $24.3700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 13 1.738888 $86.9400 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 61 104 67.983737 $3399.2200 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 22.374603 $1118.7300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 657 799 5206.258707 $260313.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 709 1301 599.866387 $5998.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 129 133 565.300404 $40385.0900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.428571 $138.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 206 214 693.469054 $49541.5000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.071429 $4.0800 $57.1400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 211 226 1072.866666 $76645.6500 $71.4400
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Subtotal (Total Children Is Unduplicated) 936 2794 8232.358446 $437631.7800 $53.1600
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Total 3546 8486.866522 $443874.3000 $52.3000
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Number of Children (Unduplicated) With at Least One Authorization 983