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: 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
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1 0.400000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.400000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 6 1.711111 $31.5900 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 6 1.711111 $17.1500 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 6 1.711111 $14.3900 $8.4100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 6 1.711111 $35.9300 $21.0000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.011111 $0.2400 $22.0000
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Subtotal (Total Children Is Unduplicated) 5 25 6.855555 $99.3000 $14.4800
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 4 5 1.455555 $72.7800 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1304 2137 3224.155832 $161209.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1302 2120 3213.327269 $160667.7700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1304 2112 3207.060601 $160354.4300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1301 2141 3237.368533 $161869.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 555 640 3474.757148 $173737.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 124 144 759.342059 $51544.1700 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 184 211 1130.127774 $76713.0700 $67.8800
SENS -V5014 HEARING AID REPAIR BY MANUFACTURER 1 1 0.255556 $29.1400 $114.0200
SENS -V5264 EARMOLD 4 5 1.688889 $30.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 15 15 8.233333 $411.6700 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 369 426 2409.859525 $163581.2400 $67.8800
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 548 2003 249655.147620 $124827.5700 $0.5000
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Subtotal (Total Children Is Unduplicated) 1317 11960 270322.779694 $1235049.0300 $4.5700
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Total 11986 270330.035249 $1235148.3300 $4.5700
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Number of Children (Unduplicated) With at Least One Authorization 1317