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
----------------------------------------------------------------------------
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 30 31 10.233331 $133.5400 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 30 31 10.233331 $93.2200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 31 10.233331 $95.5800 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 30 31 10.233331 $222.3700 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 26 9.188887 $224.8500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 19 20 66.500002 $3990.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.688889 $31.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.377778 $273.4500 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 42.977779 $2084.4300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 1.422223 $68.9800 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 13 16.255555 $788.3900 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 76 209 180.344437 $8005.8200 $44.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 6.000000 $9000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 21.957142 $1097.8600 $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 96 109 36.022223 $1801.1200 $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 192 216 95.444450 $4772.2500 $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 193 247 1961.004768 $98050.2700 $50.0000
INTR -INTR INTERPRETER 2 4 0.116666 $5.8300 $49.9700
OCCT -97530 OT SESSION BY LICENSED OT 71 89 331.783334 $22521.4600 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.066667 $57.9400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 80 99 352.641667 $23937.3200 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.377778 $688.9000 $500.0100
SENS -V5264 EARMOLD 1 1 1.377778 $24.8000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.800000 $40.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 159 680.961905 $46223.6900 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 5.600000 $73.9200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 516 734 120657.236497 $60328.6200 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 705 1956 124322.562309 $275172.1600 $2.2100
-------------------------------------------------------------------------------------------------------------------------------------
Total 2240 124541.951189 $283177.9800 $2.2700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 805