Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2017 FSPSA's found
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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.059525 $2.2000 $36.9800
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Subtotal (Total Children Is Unduplicated) 1 1 0.059525 $2.2000 $36.9800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.922222 $44.7300 $48.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.172222 $8.0600 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.344444 $41.1900 $119.5800
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 18 10.764284 $549.5100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 47 48 16.187302 $826.3700 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 28 31 6.622220 $338.0500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 28 28 12.774972 $652.1600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.033333 $1.7000 $51.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 51 53 30.507144 $1557.3900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.050000 $2.5500 $51.0500
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Subtotal (Total Children Is Unduplicated) 129 184 78.378143 $4021.7100 $51.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.002740 $13.5000 $4927.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.033333 $51.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 42 4.638892 $231.9600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 5 2.111111 $105.5600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 112 133 729.571434 $18239.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 601 664 4067.141099 $203357.0300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 574 656 4054.073050 $40540.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 87 99 478.971431 $34217.7200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 62.865080 $3595.8700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 80 89 498.428576 $35607.7200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 51.642857 $2951.9100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.344444 $81.6600 $237.0900
SENS -V5264 EARMOLD 1 1 0.344444 $6.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 116 513.226994 $36664.9200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 4.390476 $60.9400 $13.8800
TRAV -TRAVS Travel by mile 1 1 3.857143 $1.7200 $0.4400
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Subtotal (Total Children Is Unduplicated) 786 1832 10472.643104 $375728.3800 $35.8800
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Total 2017 10551.080772 $379752.2900 $35.9900
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Number of Children (Unduplicated) With at Least One Authorization 791