Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 13 14 25.320636 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 14 25.320636 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 23 12.111108 $587.3700 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 1.038888 $62.3300 $59.9900
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.100000 $49.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.111111 $242.7800 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 173 182 47.111105 $2284.8600 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 130 143 32.927773 $1596.9700 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 93 100 36.222228 $1756.8100 $48.5000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 346 457 132.622213 $6580.6200 $49.6200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 6.168253 $308.4200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 30 10.511112 $525.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 33 16.766664 $838.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 10 10.955554 $547.7700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 51 52 262.152378 $6553.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 658 715 4355.416688 $217770.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 222 239 1311.376995 $89016.1700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 184 205 1041.971433 $70728.9800 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.005555 $65.3600 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.005555 $229.2500 $227.9900
SENS -V5264 EARMOLD 3 3 2.155555 $38.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 16 42.192063 $2109.6000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 142 156 802.928576 $54502.7700 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 659 805 6641.859555 $3320.9400 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 37.230953 $1861.5500 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 837 2277 14543.696889 $448418.0200 $30.8300
-------------------------------------------------------------------------------------------------------------------------------------
Total 2748 14701.639738 $454998.6400 $30.9500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 850