Summary Report for FSPSAs Ending During the Report Period Center: 57
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 15 15 5.111109 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 5.111109 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.111111 $5.3900 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 9 9 7.061112 $402.0600 $56.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.122222 $140.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.772221 $318.7900 $114.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 38 39 9.213489 $446.8400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 72 73 40.864282 $1981.9000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 120 127 32.286508 $1565.8900 $48.5000
WHEELP-97001TG WHEELCHAIR EVAL/ FITTING BY LICENSE 1 1 1.000000 $48.5000 $48.5000
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Subtotal (Total Children Is Unduplicated) 186 255 96.430945 $4909.8700 $50.9200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 1.066667 $53.3400 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.261111 $13.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 16.191271 $809.5700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 22 26.424603 $1321.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 349 366 190.206357 $9510.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.588889 $39.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 44 47 302.428570 $7560.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 436 476 3162.330185 $158116.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 59 62 306.892858 $20831.8700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 82 86 445.933331 $30269.9800 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 8.857143 $481.1200 $54.3200
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 3.122222 $711.8600 $228.0000
SENS -V5264 EARMOLD 2 2 3.122222 $56.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 12.714286 $635.7200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 143 157 752.964284 $51111.2200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.571429 $302.6400 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 16.714286 $220.6300 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 443 848 64232.117450 $32116.0600 $0.5000
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Subtotal (Total Children Is Unduplicated) 594 2103 69488.507164 $314161.7100 $4.5200
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Total 2373 69590.049218 $319071.5900 $4.5900
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Number of Children (Unduplicated) With at Least One Authorization 609