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: 10-01-13 and 12-31-13 Date of Report: 02-18-14 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 12 9.438889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 12 9.438889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 12 3.216666 $156.0100 $48.5000
AUDE -AUDE UNSPECIFIED AUDE SERVICES 3 3 1.288889 $77.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.288889 $58.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.577777 $296.4400 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 192 208 52.851588 $2563.3000 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.066667 $3.2400 $48.5200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 114 120 31.621431 $1533.6500 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 89 94 31.203175 $1513.3600 $48.5000
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Subtotal (Total Children Is Unduplicated) 364 445 124.181749 $6204.5500 $49.9600
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 9 10 41.609524 $2080.4800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 2 0.177778 $8.8900 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 7.822224 $391.1200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 33 11.766663 $588.3200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 9 9.327777 $466.3900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 60 66 430.071418 $10751.8100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 644 737 4094.406290 $204720.5000 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 2 2 0.816666 $40.8300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 234 262 1460.446011 $99135.1700 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 2 2 22.000000 $1195.0400 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 156 178 850.214281 $57712.6000 $67.8800
PHY -97110HM PT SESSION BY PT ASST 2 2 16.857143 $915.6800 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.866667 $56.3400 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 3 3 1.288889 $293.8700 $228.0000
SENS -V5264 EARMOLD 8 8 10.091269 $181.6400 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 16 17 35.715872 $1785.8000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 141 152 720.159523 $48884.4200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.361111 $4.7700 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 622 768 6110.461870 $61104.6300 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 6 6 49.571428 $24.7900 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 5 6 17.223809 $861.2000 $50.0000
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Subtotal (Total Children Is Unduplicated) 842 2279 13891.256213 $491204.2500 $35.3600
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Total 2736 14024.876851 $497408.8000 $35.4700
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Number of Children (Unduplicated) With at Least One Authorization 854