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 3911 FSPSA's found of which 1479 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 5 5 4.011111 $148.4100 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 4.011111 $148.4100 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 62 62 29.455552 $439.7700 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 59 61 23.961111 $460.0500 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 62 63 29.966663 $312.2500 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 61 62 29.449997 $257.6800 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.205556 $1.6600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 62 62 29.455552 $643.3000 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 33 33 14.905553 $970.9300 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 60 61 28.444441 $651.3700 $22.9000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 8 5.377777 $274.5300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 5.666666 $289.2800 $51.0500
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Subtotal (Total Children Is Unduplicated) 100 421 196.888868 $4300.8200 $21.8400
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 358 466 4782.769816 $239138.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1197 2266 1628.882238 $16288.7800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 66 69 605.154768 $43232.2700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.428571 $138.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 83 94 547.443658 $39109.4000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.571429 $261.3000 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 140 1008.111915 $72019.5300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.428571 $89.2300 $13.8800
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Subtotal (Total Children Is Unduplicated) 1377 3485 8988.857435 $430431.3300 $47.8800
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Total 3911 9189.757414 $434880.5600 $47.3200
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Number of Children (Unduplicated) With at Least One Authorization 1391