Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01-01-13 and 03-31-13 Date of Report: 05-17-13 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 11 14 12.199207 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 14 12.199207 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 9.272224 $449.7100 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 0.238889 $14.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.205555 $9.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.200000 $138.0000 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 159 171 47.394439 $2298.6000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 115 128 29.485713 $1430.0500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 84 90 31.534128 $1529.4100 $48.5000
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Subtotal (Total Children Is Unduplicated) 303 413 119.330948 $5869.3600 $49.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.494444 $2472.0000 $4999.5600
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 3.071429 $153.5800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 1.928571 $96.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 27 17.739680 $886.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 30 14.273015 $713.6500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 11 7.228571 $361.4300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 71 459.714276 $11492.8800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 600 694 4009.613447 $200480.7600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 214 238 1252.099196 $84992.5100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 176 201 977.878563 $66378.4300 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.350000 $22.7500 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 0.350000 $79.8000 $228.0000
SENS -V5264 EARMOLD 3 3 0.700001 $12.6000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 16 25.276192 $1263.8200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 135 150 743.589677 $50474.8800 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 599 771 5956.426162 $2978.2100 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 4 5 6.330951 $316.5500 $50.0000
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Subtotal (Total Children Is Unduplicated) 803 2228 13477.064175 $423177.2400 $31.4000
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Total 2655 13608.594330 $429046.6000 $31.5300
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Number of Children (Unduplicated) With at Least One Authorization 813