Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 21 21 7.699998 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 21 21 7.699998 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.213699 $2.0000 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.213699 $4.6400 $21.7300
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 2.834855 $326.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 0.030137 $1.5100 $49.9400
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 19 19 8.256349 $400.4400 $48.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 32 32 20.685801 $1003.2500 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 11.854762 $574.9500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 23 3.811794 $184.8600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 72 75 22.790887 $1105.3300 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 134 167 70.691983 $3602.9800 $50.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 0.679300 $1018.9500 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 7 7 8.949055 $447.4600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 2.857687 $142.8800 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.638814 $115.9700 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 24 24 10.510502 $525.5200 $50.0000
CONIP -CONIP CONSULT, ITDS, PHONE 26 26 42.616665 $1065.4100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 16 19.099497 $954.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 13 16 23.299999 $582.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 4.516666 $225.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 9 14.649999 $366.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 19 14.759132 $737.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 15 15 23.183333 $579.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 42 42 298.161910 $14908.0800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 4 5 26.641639 $1332.0900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 76 471.015475 $31972.5400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 7 7 30.500000 $1656.7600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 37 39 235.661906 $15996.7200 $67.8800
PHY -97110HM PT SESSION BY PT ASST 12 12 58.071430 $3154.4400 $54.3200
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 0.630137 $315.0500 $499.9700
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.069407 $69.5100 $65.0000
SENS -V5264 EARMOLD 4 4 1.907458 $34.3300 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 20.571429 $1028.5700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 164 173 1036.947618 $70387.9900 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.000000 $380.2400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 17.571429 $231.9400 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 241 361 127135.637299 $63567.8200 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 6.230528 $311.5300 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 271 886 129517.378314 $212110.8600 $1.6400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1074 129595.770295 $215713.8400 $1.6600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 301