Summary Report for FSPSAs Initiated During the Report Period Center: 10
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
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 9.638889 $356.6400 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 9.638889 $356.6400 $37.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 15 15 14.285714 $169.4300 $11.8600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 13.285714 $110.0100 $8.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 15 15 14.285714 $148.2900 $10.3800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 14.285714 $301.1400 $21.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 9.000000 $244.7100 $27.1900
AUDE -AUDE UNSPECIFIED AUDE SERVICES 13 14 14.000000 $840.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 9 9.066667 $439.7400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 6 6 9.000000 $436.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 42 100 100.209523 $2964.8100 $29.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 9 34.000000 $51000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 16.047619 $802.3800 $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 70 76 27.155557 $1357.7900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 80 36.750000 $1837.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 37 34.627776 $1731.3800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 152 170 89.266658 $4463.2900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 17 112.533335 $2813.3400 $25.0000
EIIF -90801 PSYCHIATRIC DIAG INTERVIEW 2 2 11.333333 $566.6700 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 2 16.666667 $416.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 161 197 1442.777781 $72138.9100 $50.0000
INTR -INTR INTERPRETER 2 9 18.000000 $900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 67 280.483336 $19039.2300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 3 3 16.933333 $919.8200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 93 115 306.266668 $20789.3900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 11.933333 $648.2200 $54.3200
SCONLY-SCONLY SERVICE COORDINATION ONLY 74 77 77.000000 $77.0000 $1.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 2 2 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 141 789.618248 $53599.2400 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.600000 $86.9100 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 12.000000 $158.4000 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 3 3 309.333333 $154.6700 $0.5000
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Subtotal (Total Children Is Unduplicated) 584 1168 3789.557930 $241009.8300 $63.6000
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Total 1272 3899.406342 $244331.2800 $62.6600
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Number of Children (Unduplicated) With at Least One Authorization 597