Summary Report for FSPSAs Ending During the Report Period Center: 51
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
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 4.000000 $194.0000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 3.000000 $145.5000 $48.5000
VISF -VISF VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 10 10 10.000000 $629.5000 $62.9500
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 2.857143 $142.8600 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 91 98 41.180558 $2059.0400 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 0.475000 $11.8800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 48 24.859130 $1242.9800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.050000 $1.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 54 26.570240 $1328.5300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.050000 $1.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 104 106 49.588496 $2479.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.983334 $49.5900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 26.857143 $1342.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 93 530.401589 $26520.0900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 54 298.540476 $20264.9100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $85.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 58 59 291.933332 $19816.4500 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 6.035714 $327.8600 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.000000 $500.0000 $500.0000
SENS -V5264 EARMOLD 1 1 0.444444 $8.0000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 5.714286 $285.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 101 637.490475 $43272.8300 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.857143 $50.9100 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 160 246 30895.846019 $15447.9200 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 3 11.142857 $557.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 178 878 32858.448808 $135796.8400 $4.1300
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Total 888 32868.448808 $136426.3400 $4.1500
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Number of Children (Unduplicated) With at Least One Authorization 180