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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2166 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 3 3.221429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.221429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.461111 $95.1800 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.922222 $43.1600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.938889 $112.2900 $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 12 12 4.811109 $245.6000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 31 33 17.821431 $909.7900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 16 6.072221 $309.9800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 12 14 2.855557 $145.7800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 64 67 24.538893 $1252.7300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 0.333333 $17.0200 $51.0500
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Subtotal (Total Children Is Unduplicated) 112 152 65.754766 $3523.0300 $53.5800
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 7.839682 $391.9900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 153 159 124.301582 $6215.0500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 11.055555 $552.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 366 373 254.782541 $12739.1300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 175 182 1376.276996 $68813.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 544 1139 4719.361144 $47193.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 27 209.892860 $14994.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.428571 $196.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 21 21 119.180952 $8514.2800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 31.579366 $1805.0700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 4.000000 $948.4800 $237.1200
SENS -V5264 EARMOLD 2 2 1.300000 $23.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 42 327.128574 $23370.0400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.714286 $93.1900 $13.8800
TRAV -TRAVS Travel by mile 27 34 31948.190475 $14216.9400 $0.4500
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Subtotal (Total Children Is Unduplicated) 582 2011 39145.032584 $200068.5800 $5.1100
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Total 2166 39214.008779 $203591.6100 $5.1900
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Number of Children (Unduplicated) With at Least One Authorization 597