Summary Report for FSPSAs Ending During the Report Period Center: 07
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 1573 FSPSA's found of which 19 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 5 510.285714 $18880.5700 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 510.285714 $18880.5700 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.555556 $26.1600 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.033333 $0.5000 $14.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.033333 $0.6400 $19.1800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.121004 $1.2600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.033333 $0.7300 $21.9300
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 0.953881 $8.3500 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 0.948402 $20.7200 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 0.121004 $3.5000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.123288 $8.0300 $65.1500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 0.742922 $17.0100 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.066666 $1.7000 $25.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 6 4.408067 $206.3000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 8.623940 $1031.4200 $119.6000
EXIT -EXIT EXIT ASSESSMENT 43 47 4.514688 $225.7100 $49.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 6.571429 $492.8600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 0.027397 $2.0600 $75.0100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 17 20 0.073974 $4.0800 $55.1300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 17 0.057536 $4.2800 $74.4300
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 1.329985 $67.9000 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 5 5 0.561643 $84.2400 $149.9900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.309893 $15.8200 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 3.796652 $193.8200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 0.235616 $12.0300 $51.0500
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Subtotal (Total Children Is Unduplicated) 93 162 34.243542 $2429.0900 $70.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071233 $356.0000 $4997.6800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 4.622222 $231.1100 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.552381 $254.3900 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 0.072222 $5.1700 $71.5900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.488889 $116.9400 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 45 48 31.357044 $1567.8700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, FACE TO FACE 46 78 230.288890 $11514.4300 $50.0000
CONIP -CONIP CONSULT, PHONE 3 5 7.866667 $196.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.000000 $300.0000 $50.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 0.010959 $0.5500 $50.1900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 521 570 3919.518008 $195975.9000 $50.0000
INTR -T1013 INTERPRETER 3 3 12.005480 $600.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 50 54 365.919766 $3659.2000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 10 47.142857 $3367.8900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 13 13 76.785715 $5485.5700 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.642542 $152.3700 $237.1400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.323288 $153.3200 $474.2600
SENS -V5264 EARMOLD 7 7 22.894455 $412.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 59 428.059531 $30580.5900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 24.714286 $343.0300 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 410 526 3455.863457 $1727.9300 $0.5000
TRAV -TRAVS Travel by mile 8 10 40.705479 $18.1100 $0.4400
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Subtotal (Total Children Is Unduplicated) 578 1406 8678.910927 $257019.5500 $29.6100
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Total 1573 9223.440183 $278329.2200 $30.1800
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Number of Children (Unduplicated) With at Least One Authorization 623