Summary Report for FSPSAs Ending During the Report Period Center: 10
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 13.705557 $507.1100 $37.0000
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Subtotal (Total Children Is Unduplicated) 9 9 13.705557 $507.1100 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 102 103 101.571428 $1204.6400 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 100 101 99.571428 $824.4500 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 100 101 99.571428 $1033.5500 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 100 101 99.571428 $2098.9700 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 71 72 71.285714 $1938.2600 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 97 107 106.333333 $6380.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.000000 $575.0000 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 18 19 26.933333 $1346.6700 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 41 49 51.100000 $2478.3500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 12 12.000000 $582.0000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 40 46 52.038878 $2523.8900 $48.5000
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Subtotal (Total Children Is Unduplicated) 283 718 726.976970 $21075.7600 $28.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 35 160.000000 $240000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 22.190475 $1109.5300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 124 147 139.730953 $6986.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 77 84 30.036108 $1501.7900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 61 22.611112 $1130.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 4.166664 $208.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 159 84.408335 $4220.4300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 35 217.666666 $5441.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.333333 $166.6700 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 5.800000 $145.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 316 404 2643.141663 $132157.0700 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 11 40.833333 $2041.6700 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 205 265 1056.133333 $71690.3300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 11 11 55.699999 $3025.6200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 335 426 1380.183343 $93686.9100 $67.8800
PHY -97110HM PT SESSION BY PT ASST 8 8 41.933334 $2277.8200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 98 104 104.000000 $104.0000 $1.0000
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.000000 $500.0000 $500.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 9 9 16.000000 $288.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 9 10 19.283333 $964.1700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 363 462 1743.769444 $118367.0700 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 19.133333 $1039.3200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 33.000002 $435.6000 $13.2000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 11.300000 $565.0000 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 14 18 61.597223 $3079.8700 $50.0000
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Subtotal (Total Children Is Unduplicated) 924 2293 7937.451986 $692501.4300 $87.2400
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Total 3020 8678.134513 $714084.3000 $82.2900
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Number of Children (Unduplicated) With at Least One Authorization 1048