Summary Report for FSPSAs Ending During the Report Period Center: 57
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 7 7 2.955555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 2.955555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 4 4 1.083334 $67.8500 $62.6300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.866667 $39.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 5.066666 $582.6600 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 30 31 17.891269 $867.7200 $48.5000
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.211111 $10.2400 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 26 26 7.611111 $369.1400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 73 78 37.745241 $1830.6500 $48.5000
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Subtotal (Total Children Is Unduplicated) 102 144 70.475399 $3767.2600 $53.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.211111 $1055.5000 $4999.7400
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 68 86.435717 $4321.8000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.877778 $21.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 33 32.043653 $1602.2000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 388 411 300.355568 $15017.8200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.500000 $12.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 161 174 1050.999998 $52550.0200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 18 93.478571 $6345.3300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 26 26 164.142854 $11142.0300 $67.8800
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 1 1 0.866667 $197.6100 $228.0100
SENS -V5264 EARMOLD 2 2 1.566667 $28.2000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 0.900000 $45.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 91 542.928567 $36854.0300 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.714286 $473.3600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 15.428571 $203.6600 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 420 837 3019.137291 $30191.3900 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 95 113 2938.658729 $1469.3300 $0.5000
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Subtotal (Total Children Is Unduplicated) 549 1783 8257.246028 $161531.7200 $19.5600
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Total 1934 8330.676982 $165298.9800 $19.8400
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Number of Children (Unduplicated) With at Least One Authorization 567