Summary Report for FSPSAs Initiated During the Report Period Center: 06
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 3933 FSPSA's found of which 27 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 76 80 156.051679 $5773.9500 $37.0000
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Subtotal (Total Children Is Unduplicated) 76 80 156.051679 $5773.9500 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 15.714286 $735.4300 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 20 14.318189 $1712.4700 $119.6000
EXIT -EXIT EXIT ASSESSMENT 16 16 2.989953 $149.5000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.306850 $15.6700 $51.0600
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 3 3 2.888889 $433.3400 $150.0000
SCREEN-T1023 SCREENING 25 26 15.866666 $793.3300 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.131507 $2.0500 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.213698 $10.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 63 73 52.430038 $3852.6900 $73.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.084932 $424.5000 $4998.1200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 10 10 10.961903 $548.0900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 13 17.250794 $862.5500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 5.500000 $393.8600 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 0.257534 $61.6200 $239.2600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 156 163 40.413033 $2020.7200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 0.705555 $17.6400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 78 176 259.396833 $12969.8900 $50.0000
CONIP -CONIP CONSULT, PHONE 17 39 51.076189 $1276.9000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 101.142858 $2528.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 104 125 2628.838740 $65720.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 633 796 5964.531006 $298226.9600 $50.0000
INTR -T1013 INTERPRETER 30 32 127.332155 $6366.6300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 990 1532 10841.956645 $108419.7100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 123 148 576.561913 $41189.5300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 31 36 156.228573 $8936.2700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 156 194 696.011124 $49722.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 57 67 221.246825 $12646.4400 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 12 12 4.420091 $287.3100 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.216438 $25.6600 $118.5400
SENS -V5050 IN EAR MONAURAL HEARING AID 10 10 8.773974 $2080.5100 $237.1200
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.131507 $31.1800 $237.1100
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 4 4 0.257534 $122.1600 $474.3600
SENS -V5264 EARMOLD 45 56 104.750351 $1885.5100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 273 330 1510.554783 $107914.0100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 16 16 197.214286 $2737.3400 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 1 4 48.000000 $24.0000 $0.5000
TRAV -TRAVS Travel by mile 2 2 11.133333 $4.9500 $0.4400
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Subtotal (Total Children Is Unduplicated) 1159 3780 23584.948909 $727446.3800 $30.8400
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Total 3933 23793.430626 $737073.0200 $30.9800
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Number of Children (Unduplicated) With at Least One Authorization 1248