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 4 4 1.033333 $14.8400 $14.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.033333 $19.0700 $18.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.033333 $10.3500 $10.0200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.033333 $8.6900 $8.4100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 1.033333 $8.0100 $7.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.033333 $21.7000 $21.0000
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 1.033333 $64.7200 $62.6300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.033333 $22.7500 $22.0200
AUDE -AUDE UNSPECIFIED AUDE SERVICES 17 17 164.733334 $9884.0000 $60.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.844444 $97.1100 $114.9900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 17 8.544445 $414.4100 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 3 1.488889 $72.2100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 13 7.633334 $370.2200 $48.5000
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Subtotal (Total Children Is Unduplicated) 46 83 191.511110 $11008.0800 $57.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.633333 $3166.5000 $4999.7400
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 53 56 41.399997 $2069.9900 $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 214 243 2010.627772 $100531.3600 $50.0000
INTR -INTR INTERPRETER 2 2 6.422222 $321.1100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 77 456.319049 $30974.9500 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 68 72 365.688891 $24822.9800 $67.8800
SENS -V5264 EARMOLD 2 2 2.622222 $47.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 142 153 893.319044 $60638.4700 $67.8800
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
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Subtotal (Total Children Is Unduplicated) 794 2082 10419.181333 $306393.2800 $29.4100
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Total 2186 10620.559110 $317401.3600 $29.8900
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Number of Children (Unduplicated) With at Least One Authorization 826