Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 5 5 2.866666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 2.866666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 18 18 7.211905 $451.6900 $62.6300
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.166667 $10.0000 $60.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 4.456347 $512.4600 $115.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.194444 $9.4300 $48.4900
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 66 67 17.616665 $854.4000 $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 70 70 28.767463 $1395.2400 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 168 177 55.406345 $2687.1800 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.200000 $120.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 268 342 115.230947 $6050.6400 $52.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.211111 $1055.5000 $4999.7400
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 1 0.866667 $43.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 63 71.883330 $3594.1600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 21.619047 $1080.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 316 327 252.748408 $12637.4100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.594444 $39.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 58 63 410.714283 $10267.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 381 396 2928.686496 $146434.3200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 91 493.591269 $33504.9800 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 5 5 37.607142 $2042.8200 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 98 102 568.928568 $38618.8900 $67.8800
PHY -97110HM PT SESSION BY PT ASST 3 3 13.934921 $756.9400 $54.3200
SENS -V5264 EARMOLD 3 3 1.155556 $20.8000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 3 3.044444 $152.2200 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 187 200 1079.686109 $73289.1200 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 4 24.785715 $1346.3600 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 40.285715 $531.7700 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 346 691 2736.624582 $27366.2400 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 93 114 4434.315074 $2217.1600 $0.5000
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Subtotal (Total Children Is Unduplicated) 639 2116 13122.282881 $355000.6900 $27.0500
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Total 2463 13240.380494 $361051.3300 $27.2700
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Number of Children (Unduplicated) With at Least One Authorization 657