Summary Report for FSPSAs Ending During the Report Period Center: 10
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 70 75 39.044443 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 70 75 39.044443 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 110 112 36.885706 $481.3500 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 110 112 35.141261 $320.1300 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 108 109 35.130150 $328.1100 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 109 111 35.152372 $763.8400 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 92 94 29.030151 $710.3500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 70 75 281.066672 $16864.0300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 5.769863 $259.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 9.784171 $1125.1800 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 10 11 2.000000 $100.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 3 0.494445 $27.4400 $55.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 48 48 98.311114 $4768.1000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 3.466667 $168.1400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 43 46 74.477778 $3612.1700 $48.5000
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Subtotal (Total Children Is Unduplicated) 265 745 646.710350 $29528.4900 $45.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 18 26.911111 $40366.6500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 11 11 39.738094 $1986.9100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 105 132 24.272228 $1213.6400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 1.016668 $25.4200 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 97 110 36.588890 $1829.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 79 31.366663 $1568.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.427778 $10.7000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 50 27.516666 $1375.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 193 217 96.011117 $4800.5900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 17 69.771431 $1744.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.600000 $480.0000 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 5.200000 $130.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 511 658 4382.098423 $219104.9700 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 1 1 2.800000 $140.0000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 11 11 75.242857 $3762.1500 $50.0000
INTR -INTR INTERPRETER 2 4 0.116666 $5.8300 $49.9700
OCCT -97530 OT SESSION BY LICENSED OT 230 283 1175.466665 $79790.6600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 18.200000 $988.6200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 321 385 1356.575395 $92084.3200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 5 5 17.100000 $928.8700 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 7.288890 $3644.5000 $500.0100
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 2.717504 $619.5900 $228.0000
SENS -V5264 EARMOLD 8 9 10.073061 $181.3200 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 13 17 56.255555 $2812.7800 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 12 13 38.332541 $1916.6300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 327 412 1693.909524 $114982.5800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.400000 $97.6800 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 517 736 121083.903163 $60541.9500 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 5 5 15.067857 $753.3900 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 25 25 138.036111 $6901.8100 $50.0000
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Subtotal (Total Children Is Unduplicated) 977 3223 130449.004858 $644789.4200 $4.9400
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Total 4043 131134.759651 $674317.9100 $5.1400
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Number of Children (Unduplicated) With at Least One Authorization 1152