Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 10-01-11 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $61.0000 $15.2500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.000000 $33.1200 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 4.000000 $41.5200 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 4.000000 $84.3200 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $27.1900 $27.1900
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $48.5000 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5 18 18.000000 $295.6500 $16.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.000000 $7500.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.000000 $250.0000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 260 289 302.829366 $15141.4800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 17 16.105556 $805.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 20.000000 $1000.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 256 285 304.128571 $15206.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 359 393 2302.380966 $115118.9300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 152 183 936.388099 $63561.9900 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 202 234 1270.804762 $86262.2100 $67.8800
SCONLY-SCONLY SERVICE COORDINATION ONLY 5 5 5.319047 $5.3200 $1.0000
SENS -V5264 EARMOLD 5 5 5.000000 $90.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 1.000000 $50.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 14 14.000000 $700.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 394 474 2594.895244 $176141.4200 $67.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 763 1930 7782.851611 $481833.0500 $61.9100
-------------------------------------------------------------------------------------------------------------------------------------
Total 1948 7800.851611 $482128.7000 $61.8000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 763