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: 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 8 8 9.000001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 9.000001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 9 2.149999 $104.2700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.253968 $56.7800 $45.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 0.388889 $17.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.477778 $54.9500 $115.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 153 167 50.037298 $2426.8000 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 120 129 50.018259 $2425.9100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 74 78 21.988891 $1066.4700 $48.5000
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Subtotal (Total Children Is Unduplicated) 317 390 126.315082 $6152.6800 $48.7100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 6 6 17.867461 $893.3800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.066667 $3.3400 $50.0200
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 8.277776 $413.8800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 36 22.344445 $1117.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 8.272222 $413.6100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 54 56 332.642857 $8316.0900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 644 707 4699.303958 $234965.3800 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 1 1 0.088889 $4.4500 $50.0100
OCCT -97530 OT SESSION BY LICENSED OT 201 220 1427.779359 $96917.7100 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 41.571429 $2258.1600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 167 186 1112.078573 $75487.9300 $67.8800
PHY -97110HM PT SESSION BY PT ASST 4 4 41.428572 $2250.4000 $54.3200
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.150000 $9.7500 $65.0000
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 0.238889 $54.4700 $228.0100
SENS -V5264 EARMOLD 4 4 1.883334 $33.9000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 14 14 28.041270 $1402.0600 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 120 131 813.007143 $55186.9000 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 645 760 7011.988072 $70119.9100 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 4 4 19.857143 $9.9300 $0.5000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 13.571428 $678.5800 $50.0000
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Subtotal (Total Children Is Unduplicated) 850 2162 15600.459487 $550537.0300 $35.2900
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Total 2560 15735.774570 $556689.7000 $35.3800
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Number of Children (Unduplicated) With at Least One Authorization 857