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: 10-01-11 and 12-31-11 Date of Report: 02-15-12 Page: 1
Eligibility Filter: Program Patients
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 -92585 AUD EVOKED RESPONSE (DIAG) 1 1 1.000000 $51.7600 $51.7600
AUDE -AUDE UNSPECIFIED AUDE SERVICES 17 19 19.000000 $1140.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.000000 $180.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 6.233333 $716.8300 $115.0000
EXIT -EXIT TRANSITION ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 50 69 143.500000 $10762.5000 $75.0000
MED -MED UNSPECIFIED MED OFFICE VISIT 2 2 2.000000 $300.0000 $150.0000
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 1 1 1.000000 $50.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 8 8 8.000000 $388.0000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $48.5000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 11.000000 $533.5000 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 26 26 45.515079 $2207.4800 $48.5000
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Subtotal (Total Children Is Unduplicated) 119 160 269.248412 $17916.0700 $66.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $1500.0000 $1500.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.488889 $33.6700 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 10 11 14.044444 $702.2200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 11 10.166667 $508.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 98 111 120.264285 $6013.2200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 10 11 11.500000 $287.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 34 47.314285 $2365.7200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 13.928571 $348.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 27 34.142857 $1707.1400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 65 68 76.185713 $3809.2900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 13 13 12.916667 $322.9200 $25.0000
ECE -ECE EARLY CHILDHOOD EDUCATION 1 1 8.857143 $110.7100 $12.5000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 71.000000 $1775.0000 $25.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 2.400000 $60.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 403 444 2706.057145 $135302.8800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 30.285714 $1514.2900 $50.0000
INTR -INTR INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 36 222.533334 $15105.5700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 5 26.500000 $1439.4900 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 46 47 222.642859 $15113.0100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 6 26.142857 $1420.0800 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 59 61 60.011112 $60.0100 $1.0000
SENS -FM FM RECEIVER HEARING AID 2 2 3.000000 $4950.0000 $1650.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.000000 $1500.0000 $500.0000
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 8 9 13.577778 $244.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 109 594.250005 $40337.6800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 15 16 82.857143 $1093.7100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 13 15 80.142856 $40.0700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.214286 $110.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 602 1062 4505.424610 $238570.8200 $52.9500
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Total 1222 4774.673022 $256486.9000 $53.7200
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Number of Children (Unduplicated) With at Least One Authorization 663