Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 3515 FSPSA's found of which 17 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 10 11 987.307936 $36530.3900 $37.0000
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Subtotal (Total Children Is Unduplicated) 10 11 987.307936 $36530.3900 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 7 8 2.913090 $137.1800 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 1.179605 $17.6100 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 7.022527 $134.8300 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 1.799087 $18.7500 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 0.992238 $21.7800 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 21 22 3.600457 $31.5100 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 24 25 10.964232 $239.4700 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 0.285388 $8.2500 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.298630 $19.4500 $65.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 19 19 3.362101 $77.0000 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.231050 $5.9000 $25.5200
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 8 4.912177 $229.8900 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 8 8.993803 $1075.6600 $119.6000
EXIT -EXIT EXIT ASSESSMENT 50 54 5.314688 $265.7100 $49.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 59.142858 $4435.7200 $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 15 18 13.200393 $990.0000 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 15 2.906926 $148.4000 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 5 5 0.561643 $84.2400 $149.9900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 6 6.746030 $344.3800 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.136986 $2.1400 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 26 26 28.396706 $1449.6500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 18.778103 $958.6200 $51.0500
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Subtotal (Total Children Is Unduplicated) 149 280 181.840089 $10702.2600 $58.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.323288 $1616.5000 $5000.1900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.477778 $23.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 17 25.015384 $1250.7800 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.030159 $288.6000 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 0.674505 $48.3000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.606697 $145.1200 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 107 107.557838 $5377.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 8 8.872225 $221.8100 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 176 354 1180.569852 $59028.5700 $50.0000
CONIP -CONIP CONSULT, PHONE 10 17 36.595239 $914.8900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.285714 $82.1400 $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 1124 1429 12553.939374 $627697.7100 $50.0000
INTR -T1013 INTERPRETER 8 8 102.862622 $5143.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 94 107 1012.351507 $10123.5300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 24 242.999998 $17359.9500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 15.428571 $882.5200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 27 33 253.598416 $18117.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 20.428571 $1167.7000 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.316667 $37.5500 $118.5700
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 9 10 24.426266 $439.6700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 111 127 1157.345237 $82680.8400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 4 32.285714 $448.1300 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 724 922 8034.977741 $4017.4800 $0.5000
TRAV -TRAVS Travel by mile 27 32 212.134051 $94.4000 $0.4400
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Subtotal (Total Children Is Unduplicated) 1199 3224 25038.080203 $837814.4700 $33.4600
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Total 3515 26207.228228 $885047.1200 $33.7700
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Number of Children (Unduplicated) With at Least One Authorization 1217