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 1135 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
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 3.000000 $26.2500 $8.7500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.966667 $75.7400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.246575 $11.5400 $46.8000
EXIT -EXIT EXIT ASSESSMENT 2 2 0.522222 $26.1100 $50.0000
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 1 1 0.066667 $10.0100 $150.0700
SCREEN-T1023 SCREENING 6 6 2.333789 $116.6900 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.355556 $18.1500 $51.0600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10 13 9.491476 $284.4800 $29.9700
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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 12 47.192858 $2359.6400 $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 9 9 34.524999 $2466.4700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.100000 $62.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 6 7 60.214286 $4301.7100 $71.4400
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 29 149.620236 $10688.8500 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 253 470 3869.704957 $1934.8500 $0.5000
TRAV -TRAVS Travel by mile 41 56 432.620637 $192.5200 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 340 1122 5376.983403 $62388.0000 $11.6000
-------------------------------------------------------------------------------------------------------------------------------------
Total 1135 5386.474879 $62672.4900 $11.6400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 340