Summary Report for FSPSAs Initiated During the Report Period Center: 10
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 51 52 26.188887 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 51 52 26.188887 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 109 111 35.130150 $458.4400 $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 69 76 193.577783 $11614.7000 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 2.880974 $129.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 6.717503 $772.5000 $115.0000
EVAL -EVAL DEVELOPMENTAL EVALUATION 1 1 0.055556 $2.7800 $50.0400
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 2 0.266667 $14.8000 $55.5100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 38 19.433336 $942.5300 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.211111 $58.7400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 41 44 16.566669 $803.4900 $48.5000
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Subtotal (Total Children Is Unduplicated) 247 717 410.293683 $16920.0600 $41.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 37.533333 $56299.9500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 28.561904 $1428.1000 $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 104 106 36.683332 $1834.1600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 74 46.299999 $2315.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 53 39.188887 $1959.4400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 180 197 101.038887 $5051.9400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 54.933335 $1373.3400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.344444 $17.2200 $49.9900
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 532 654 4607.336508 $230366.8300 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 20 20 94.591667 $4729.5900 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 2.900000 $145.0000 $50.0000
INTR -INTR INTERPRETER 2 4 0.116666 $5.8300 $49.9700
OCCT -97530 OT SESSION BY LICENSED OT 236 275 1317.601593 $89438.8300 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.800000 $260.7400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 327 384 1494.194445 $101425.9200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 12.666666 $688.0500 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 6 6 4.999999 $2499.9500 $499.9900
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.717504 $391.5900 $228.0000
SENS -V5264 EARMOLD 11 12 9.428613 $169.7100 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 13 19 40.200000 $2010.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 4 4 13.544445 $677.2300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 350 425 2003.265078 $135981.6100 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.266667 $148.7200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 608 816 140770.614299 $70385.3100 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 19 19 85.425000 $4271.2500 $50.0000
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Subtotal (Total Children Is Unduplicated) 992 3251 150844.542167 $715114.3400 $4.7400
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Total 4020 151281.024737 $732034.4000 $4.8400
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Number of Children (Unduplicated) With at Least One Authorization 1087