Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-12 and 12-31-12 Date of Report: 02-16-13 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
SCONLY-SCONLY SERVICE COORDINATION ONLY 26 26 907.422223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 26 907.422223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 6.411110 $310.9300 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 5.166666 $310.0000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.044445 $47.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.056316 $121.4700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.466667 $123.3400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 2.714286 $131.6400 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.145205 $2.1800 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 2 2 0.137367 $6.6600 $48.5100
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Subtotal (Total Children Is Unduplicated) 19 23 19.142062 $1053.2300 $55.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 7.800001 $11700.1500 $1500.0200
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 9.839681 $491.9900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 19.166667 $958.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 3 6.099999 $152.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 276 434 1776.446820 $88822.3100 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 3 3 5.133334 $128.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 189 192 785.774606 $39288.7400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 10.499999 $262.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 224 227 807.696032 $40384.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 8.900000 $222.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 264 268 891.447618 $44572.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 10 10 18.500001 $462.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 14.857143 $371.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 22.409524 $1120.4800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 24.142856 $1207.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 114 116 696.500010 $34824.9700 $50.0000
INTR -INTR INTERPRETER 30 31 193.523810 $9676.2000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.428571 $232.7300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.285714 $178.4800 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 26.285715 $1784.2700 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 30.714286 $1668.4000 $54.3200
SENS -FM FM RECEIVER HEARING AID 1 1 1.766667 $2915.0600 $1650.0300
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 0.911111 $455.5500 $499.9900
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.290411 $18.8800 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.290411 $66.2100 $227.9900
SENS -V5264 EARMOLD 2 2 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 57.857144 $3927.3400 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 588 699 4097.827052 $2048.9200 $0.5000
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Subtotal (Total Children Is Unduplicated) 604 2045 9524.395183 $287997.0500 $30.2400
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Total 2094 10450.959468 $289050.2700 $27.6600
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Number of Children (Unduplicated) With at Least One Authorization 635