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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2726 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
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 1.850000 $120.5100 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.100000 $4.6800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.100000 $11.9600 $119.6000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 3.000000 $225.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 15 16 14.907937 $761.0500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 53 55 19.816666 $1011.6400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 17 17 12.728570 $649.7900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 32 34 20.128571 $1027.5600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.322222 $16.4500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 114 119 50.977775 $2602.4000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 192 252 127.931741 $6648.5900 $51.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.288889 $1444.5000 $5000.1900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.122222 $29.2300 $239.1600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 5 2.033334 $101.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 3.744445 $187.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 154 164 79.100789 $3955.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 38 18.027780 $901.4000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 435 462 242.511103 $12125.5200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.857143 $221.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 202 220 1298.038101 $64901.8800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 655 1403 4731.243656 $47312.4200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 30 273.346033 $19527.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.100000 $5.7200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 26 26 194.038099 $13862.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 15 15 74.793652 $4275.2000 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 4.000000 $948.4800 $237.1200
SENS -V5264 EARMOLD 2 2 0.744444 $13.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 52 359.750001 $25700.5300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 27.571429 $382.6900 $13.8800
TRAV -TRAVS Travel by mile 31 42 21831.011903 $9714.8000 $0.4500
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Subtotal (Total Children Is Unduplicated) 717 2474 29149.323023 $205611.0400 $7.0500
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Total 2726 29277.254764 $212259.6300 $7.2500
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Number of Children (Unduplicated) With at Least One Authorization 747