Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 04-01-13 and 06-30-13 Date of Report: 08-18-13 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 1 1 2.071429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.071429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 5 6 0.346270 $20.7700 $59.9900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.011111 $0.5000 $44.9600
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.138889 $15.9700 $115.0100
EXIT -EXIT EXIT ASSESSMENT 1 1 0.211111 $10.5600 $50.0000
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Subtotal (Total Children Is Unduplicated) 8 11 0.707381 $47.8000 $67.5700
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 1 1 0.714286 $35.7200 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 26 143 70.862498 $3543.1200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 4.900000 $245.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 3.628571 $181.4300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 2.044443 $102.2200 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.066667 $78.2100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.714286 $17.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 43 50 82.161904 $4108.1000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.150000 $7.5000 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 1 1 3.285714 $223.0300 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.000000 $195.0000 $65.0000
SENS -V5264 EARMOLD 1 1 0.088889 $1.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 7.447619 $505.5400 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.714286 $22.6300 $13.2000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 45 140 9696.276191 $4848.1400 $0.5000
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Subtotal (Total Children Is Unduplicated) 51 364 9878.055354 $14115.0700 $1.4300
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Total 376 9880.834164 $14162.8700 $1.4300
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Number of Children (Unduplicated) With at Least One Authorization 52