Summary Report for FSPSAs Ending During the Report Period Center: 07
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 37 38 1219.058730 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 38 1219.058730 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 11 11 2.863776 $171.8200 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.038889 $119.4700 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.427778 $20.7500 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 6 5.849218 $283.6900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 4.185715 $203.0100 $48.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.294444 $4.4200 $15.0000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 23 23 17.644890 $855.7700 $48.5000
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Subtotal (Total Children Is Unduplicated) 46 49 32.304710 $1658.9300 $51.3500
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.033333 $41.3300 $40.0000
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.358296 $537.4500 $1500.0200
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.357143 $93.4500 $68.8600
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 8.377778 $418.8900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 6 48.209523 $2410.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 17.857143 $446.4300 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 120 136 778.838100 $38941.8700 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 5.295238 $132.3800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 197.947620 $9897.3700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.285714 $7.1400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 98.985716 $4949.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.733333 $68.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 54 55 278.190481 $13909.5100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.714285 $67.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 70.285714 $1757.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 398 411 2449.030964 $122451.4400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 5 5 8.847620 $442.3900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 15 95.785716 $6501.9300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 26 26 121.517459 $8248.6000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 21.714287 $1179.5200 $54.3200
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.766667 $174.8100 $228.0100
SENS -V5264 EARMOLD 3 3 8.644444 $155.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 57 398.384128 $27042.2900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 142.428573 $1880.0500 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 394 485 196181.428557 $98090.7200 $0.5000
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Subtotal (Total Children Is Unduplicated) 485 1301 200941.017832 $339846.2400 $1.6900
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Total 1388 202192.381272 $341505.1700 $1.6900
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Number of Children (Unduplicated) With at Least One Authorization 531