Summary Report for FSPSAs Ending During the Report Period Center: 55
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 16 16 10.864286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 10.864286 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.197260 $8.8700 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 3.319483 $381.7400 $115.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 16 16 6.573014 $318.7900 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 29 29 4.736986 $229.7400 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 1.700000 $82.4500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 23 3.847945 $186.6200 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 69 69 17.123318 $830.4600 $48.5000
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Subtotal (Total Children Is Unduplicated) 117 154 37.528143 $2040.1800 $54.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.068493 $1602.7500 $1500.0100
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 3.146194 $157.3100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 0.010960 $0.5400 $49.2700
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 2 3 0.505480 $12.6400 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 17 17 10.794672 $539.7300 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 22 22 32.566667 $814.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 15 5.852513 $292.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 16 16.799999 $420.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 1.466666 $73.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 5.100000 $127.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 4.305554 $215.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 16.600000 $415.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 35 214.519048 $10725.9400 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 4 13.373386 $668.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 63 69 353.061907 $23965.8400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 18.000001 $977.7600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 37 38 199.383332 $13534.1400 $67.8800
PHY -97110HM PT SESSION BY PT ASST 9 9 24.642855 $1338.6100 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 0.947946 $474.0000 $500.0300
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.197260 $12.8200 $64.9800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.197260 $44.9600 $227.9300
SENS -V5264 EARMOLD 4 4 1.501370 $27.0300 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 13.428572 $671.4300 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 180 1004.255960 $68168.8800 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.142857 $1.8900 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 239 346 111909.348320 $55954.6700 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 7.087671 $354.3900 $50.0000
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Subtotal (Total Children Is Unduplicated) 263 819 113858.304943 $181591.8600 $1.5900
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Total 989 113906.697372 $183632.0400 $1.6100
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Number of Children (Unduplicated) With at Least One Authorization 308