Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 7599 FSPSA's found of which 1545 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 18 18 13.888888 $513.8900 $37.0000
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Subtotal (Total Children Is Unduplicated) 18 18 13.888888 $513.8900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 283 285 126.740931 $1892.2200 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 253 258 107.188562 $2058.0200 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 278 280 123.624265 $1288.1600 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 277 278 123.579821 $1081.3100 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 1.250000 $10.0800 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 278 283 124.479820 $2718.6100 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 144 146 63.635385 $4145.1900 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 274 277 122.174265 $2797.7700 $22.9000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 31 18.138889 $925.9900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 3.744444 $191.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 49 51 47.057143 $2402.2700 $51.0500
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Subtotal (Total Children Is Unduplicated) 449 1901 861.613525 $19510.7600 $22.6400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 14 4.734720 $236.7300 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 210 431 375.957146 $18797.8700 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 2 22.374603 $1118.7300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1182 1539 14676.553908 $733828.1700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1215 2344 1678.906047 $16789.0200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 289 327 2291.355196 $163694.4000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 25.285714 $1446.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 447 512 3008.707992 $214942.0500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 9.714287 $555.2600 $57.1600
SENS -V5264 EARMOLD 3 3 0.511111 $9.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 441 492 3635.433360 $259715.4700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.714286 $269.6600 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 19.785714 $274.6300 $13.8800
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Subtotal (Total Children Is Unduplicated) 1661 5674 25754.034084 $1411677.5100 $54.8100
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Total 7593 26629.536497 $1431702.1600 $53.7600
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Number of Children (Unduplicated) With at Least One Authorization 1688