Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 21 21 9.866667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 9.866667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 21 21 5.822223 $83.6100 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 20 20 4.966667 $91.6900 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 21 21 5.822223 $58.3400 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 20 20 5.566667 $46.8200 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 19 19 4.711111 $36.5100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 20 5.722223 $120.1700 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 20 20 4.966667 $311.0600 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 5.822223 $128.2100 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 65 67 361.966669 $21718.0100 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.888889 $40.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 3.999999 $459.9900 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 38 21.588890 $1047.0700 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 7 4.044445 $196.1600 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 42 45 26.322225 $1276.6400 $48.5000
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Subtotal (Total Children Is Unduplicated) 148 327 462.211121 $25614.2700 $55.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 11 18.622222 $93111.0000 $4999.9900
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 1.155556 $57.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 130 161 113.389291 $5669.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 137 140 152.711112 $7635.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 55 45.605553 $2280.2700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 57 41.955553 $2097.7700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 141 105.033331 $5251.6600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.933333 $223.3300 $25.0000
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.466667 $73.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 559 669 4813.183321 $240659.1100 $50.0000
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 13 13 89.316666 $4465.8300 $50.0000
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 8 8 36.400000 $1820.0000 $50.0000
INTR -INTR INTERPRETER 2 2 6.422222 $321.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 186 204 1075.832938 $73027.5500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 242 259 1153.222226 $78280.7500 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 2 2 1.444444 $329.3200 $227.9900
SENS -V5264 EARMOLD 9 9 8.800000 $158.4000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 5.000000 $250.0000 $50.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 8 9 42.455556 $2122.7800 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 293 315 1707.919044 $115933.5200 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 10.666667 $140.8000 $13.2000
TRAN -TRAN FAMILY TRANSPORTATION 1 1 7.866667 $786.6700 $100.0000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 652 964 6181.831736 $61818.3100 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 7 8 23.655557 $11.8300 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 9 9 42.680556 $2134.0300 $50.0000
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 3 4 13.322222 $666.1100 $50.0000
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Subtotal (Total Children Is Unduplicated) 955 3050 15709.392440 $699338.8000 $44.5200
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Total 3398 16181.470228 $724953.0700 $44.8000
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Number of Children (Unduplicated) With at Least One Authorization 1005