Summary Report for FSPSAs Ending During the Report Period Center: 04
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 11 12 7.261111 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 11 12 7.261111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 13 3.200002 $155.2100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.238889 $10.2700 $42.9900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.861111 $38.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.788889 $90.7200 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 103 111 29.765871 $1443.6300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 84 90 32.911908 $1596.2500 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.477778 $7.1700 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 71 76 16.827773 $816.1200 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 219 296 85.072221 $4158.1200 $48.8800
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 5.093652 $254.6900 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.050000 $2.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 22 12.114285 $605.7100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 13.588889 $679.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 11.000791 $550.0300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 57 346.428567 $8660.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 584 662 3889.817426 $194490.9100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 145 159 768.977767 $52198.2300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 133 147 735.499993 $49925.8100 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 1.100000 $550.0000 $500.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.622222 $40.4400 $65.0000
SENS -V5264 EARMOLD 2 2 2.200000 $39.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 13 13 24.525398 $1226.2800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 125 553.714279 $37586.1400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.571429 $33.9400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 559 701 4742.206323 $2371.1000 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 7 8 50.057143 $2502.8600 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 736 1942 11159.568164 $351718.3800 $31.5200
-------------------------------------------------------------------------------------------------------------------------------------
Total 2250 11251.901496 $355876.5000 $31.6300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 748