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
----------------------------------------------------------------------------
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 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 17 20 12.766668 $766.0100 $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 2.111111 $242.7800 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 6.422223 $311.4800 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 0.944445 $45.8100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 12 3.933334 $190.7700 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 69 201 76.988881 $2357.4000 $30.6200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 14.495238 $724.7700 $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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 187 229 1814.798412 $90739.9200 $50.0000
INTR -INTR INTERPRETER 2 4 0.116666 $5.8300 $49.9700
OCCT -97530 OT SESSION BY LICENSED OT 69 85 380.500006 $25828.3800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.933333 $50.7000 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 85 107 370.966667 $25181.2200 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.111111 $1055.5500 $500.0000
SENS -V5264 EARMOLD 2 2 2.111111 $38.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 125 150 699.133333 $47457.1700 $67.8800
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 608 815 140621.280966 $70310.6400 $0.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 746 1974 144209.880179 $275165.1000 $1.9100
-------------------------------------------------------------------------------------------------------------------------------------
Total 2227 144313.057947 $277522.5000 $1.9200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 811