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) 9 9 2.488889 $155.8800 $62.6300
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 0.166667 $10.0000 $60.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.577777 $66.4400 $114.9800
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 27 28 6.566668 $318.4900 $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 21 21 5.183335 $251.4000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 73 78 31.011901 $1504.0500 $48.5000
VISD -VISD VISION EVALUATION DIAGNOSTIC 1 1 1.200000 $120.0000 $100.0000
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Subtotal (Total Children Is Unduplicated) 102 141 47.406348 $2436.5000 $51.4000
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 2 2 8.142857 $203.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 127 133 916.999995 $45850.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 15 77.662699 $5271.7400 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 1 1 12.285714 $667.3600 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 25 25 122.428572 $8310.4500 $67.8800
SENS -V5264 EARMOLD 2 2 0.688889 $12.4000 $18.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.022222 $51.1100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 73 431.607141 $29297.5000 $67.8800
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 21.714286 $1179.5200 $54.3200
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.285714 $82.9700 $13.2000
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 345 689 2726.338868 $27263.3800 $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) 472 1491 9108.415038 $138858.3900 $15.2500
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Total 1637 9158.688052 $141294.8900 $15.4300
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Number of Children (Unduplicated) With at Least One Authorization 487