Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 2 2 0.828571 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.828571 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.100000 $1.6800 $16.7800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.100000 $0.9100 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.100000 $0.9300 $9.3400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.100000 $2.5300 $25.2600
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Subtotal (Total Children Is Unduplicated) 1 4 0.400000 $6.0500 $15.1200
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 3 3 2.988889 $149.4500 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 880 962 1382.592855 $69129.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 882 959 1384.915076 $69245.7400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 884 958 1379.209521 $68960.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 883 968 1385.041265 $69252.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 146 165 880.363512 $44018.1300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 15 97.451588 $6615.0100 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 12 12 63.280951 $4295.5100 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.049315 $3.2000 $64.9800
SENS -V5264 EARMOLD 1 1 0.100000 $1.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 6.533334 $326.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 28 163.458730 $11095.5600 $67.8800
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Subtotal (Total Children Is Unduplicated) 895 4081 6745.985036 $343093.2100 $50.8600
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Total 4087 6747.213607 $343099.2600 $50.8500
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Number of Children (Unduplicated) With at Least One Authorization 896