Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1673 FSPSA's found of which 7 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 1 1 0.400000 $14.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.400000 $14.8000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.233333 $33.6900 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 6.233333 $54.5400 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.233333 $70.6200 $21.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 6.300000 $160.8400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.331507 $15.5100 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.010959 $1.3200 $120.0500
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.655556 $32.7800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 0.522222 $26.1100 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.477778 $24.3900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 16 5.743987 $293.2400 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.066667 $10.0100 $150.0700
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 4.708925 $240.3900 $51.0500
SCREEN-T1023 SCREENING 31 32 9.434552 $471.7300 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 29 11.954869 $610.2900 $51.0500
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Subtotal (Total Children Is Unduplicated) 80 104 52.907021 $2045.4400 $38.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.288889 $1444.5000 $5000.1900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 7.100000 $355.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 82 105 33.081732 $1654.0900 $50.0000
CONIF -CONIF CONSULT, FACE TO FACE 192 421 725.549093 $36277.5000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 4.571429 $228.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 202 960.978528 $48048.8700 $50.0000
INTR -T1013 INTERPRETER 3 4 11.852382 $592.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 2 2.133334 $21.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 59 193.338490 $13812.1000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 11 49.617857 $2838.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 56 58 269.099208 $19224.4500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.142857 $293.9700 $57.1600
SENS -V5264 EARMOLD 4 4 3.411111 $61.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 150 164 822.084526 $58729.6800 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 255 475 3876.858103 $1938.4300 $0.5000
TRAV -TRAVS Travel by mile 41 56 432.620637 $192.5200 $0.4500
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Subtotal (Total Children Is Unduplicated) 381 1568 7397.728176 $185713.1600 $25.1000
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Total 1673 7451.035197 $187773.4000 $25.2000
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Number of Children (Unduplicated) With at Least One Authorization 400