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 2096 FSPSA's found of which 13 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 2 2 368.000000 $13616.0000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 368.000000 $13616.0000 $37.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.033334 $48.6600 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.477778 $7.1300 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.477778 $9.1700 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.087671 $0.9100 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 0.268493 $2.3500 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.180822 $3.9500 $21.8500
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.087671 $2.5300 $28.9100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.180822 $4.1400 $22.9100
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.744597 $81.6500 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 5.960470 $712.8800 $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 1 1 13.142857 $985.7200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.010959 $0.8300 $75.2800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 0.016438 $0.9100 $55.3600
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 13.159295 $986.9500 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 0.555556 $28.3600 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 5 5 0.561643 $84.2400 $149.9900
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 13.416983 $684.9500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 0.098782 $5.0400 $51.0600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 76 106 56.776637 $3916.0900 $68.9700
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) 9 9 7.571995 $378.6100 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.477778 $34.2200 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.235616 $16.8700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.488889 $116.9400 $239.2100
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 175 352 1175.703185 $58785.2300 $50.0000
CONIP -CONIP CONSULT, PHONE 10 17 36.595239 $914.8900 $25.0000
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 1 1 0.010959 $0.5500 $50.1900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 315 384 3377.739411 $168887.2200 $50.0000
INTR -T1013 INTERPRETER 8 8 102.862622 $5143.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 91 104 968.065793 $9680.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 7 105.142856 $7511.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.142857 $694.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 7 8 49.719053 $3551.9300 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.136986 $32.4900 $237.1400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.241096 $114.3400 $474.2500
SENS -V5264 EARMOLD 2 2 19.942857 $358.9700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 41 443.285713 $31668.3700 $71.4400
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 708 900 7820.692027 $3910.3400 $0.5000
TRAV -TRAVS Travel by mile 26 31 177.848337 $79.1400 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 957 1988 14416.134398 $299120.0100 $20.7500
-------------------------------------------------------------------------------------------------------------------------------------
Total 2096 14840.911035 $316652.1000 $21.3400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 969