Summary Report for FSPSAs Ending During the Report Period Center: 09
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 1 1 2.428571 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.428571 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.777778 $46.6100 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.777778 $25.3100 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 2.777778 $25.9400 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.400000 $52.1500 $21.7300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.377778 $9.5400 $25.2600
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Subtotal (Total Children Is Unduplicated) 3 12 11.111112 $159.5600 $14.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.322222 $483.3000 $1499.9000
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.777778 $138.8900 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 794 902 1272.403177 $63620.1800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 797 871 1292.624606 $64631.2500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 791 869 1244.637303 $62231.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 798 907 1280.283332 $64014.1600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 464 518 2787.293629 $139364.7700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 130 146 628.396026 $42655.5400 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 209 230 1159.084809 $78678.7300 $67.8800
SENS -V5264 EARMOLD 2 2 1.377778 $24.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 17 12.499208 $624.9700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 437 517 2387.815880 $162084.9400 $67.8800
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Subtotal (Total Children Is Unduplicated) 941 4983 12069.515748 $678553.4000 $56.2200
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Total 4996 12083.055431 $678712.9600 $56.1700
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Number of Children (Unduplicated) With at Least One Authorization 941