Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10-01-18 and 12-31-18 Date of Report: 02-05-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3633 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 0.577169 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.577169 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 48 53 29.309869 $1421.5400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.065753 $1.5600 $23.7200
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 4.857143 $218.5700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 5.218787 $600.1500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.488889 $24.4500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 43 46.325875 $2316.3000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 12.005479 $666.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 108 109 180.097253 $13507.3200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 57 95.546573 $7166.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 165 165 248.213684 $13775.9000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 98 98 169.568489 $12717.6500 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 0.443607 $22.6500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 0.536986 $27.4100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 22 7.008906 $357.8100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 1.227169 $62.6500 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 10.321330 $526.9000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 11.627006 $593.5500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 27 27 11.874574 $606.2000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 4 2.627778 $134.1500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.372222 $19.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 30 30 5.034703 $257.0200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 1.577778 $80.5500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.030137 $1.4700 $48.8800
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Subtotal (Total Children Is Unduplicated) 357 658 857.385469 $56056.5900 $65.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 56 63 36.544116 $182721.5000 $5000.0300
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.084932 $6.0800 $71.5800
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.610959 $140.5100 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 58 62 43.291364 $2164.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.005518 $0.1400 $24.9200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 264 298 537.020770 $26851.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 9.002381 $225.0600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 105 106 139.798414 $6989.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.283333 $7.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 31 37.288890 $1864.4500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.166667 $4.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 200 205 358.764280 $17938.1900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.250000 $6.2500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 3.857143 $282.8000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 622.142857 $15553.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 297 313 1878.880966 $93944.0300 $50.0000
INTR -T1013 INTERPRETER 21 31 63.826615 $3191.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 379 587 2200.404153 $22004.0200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 65 65 346.178577 $24730.9600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 68 68 397.529369 $28399.4900 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.361644 $82.4400 $227.9700
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 4.857143 $2214.8400 $456.0000
SENS -V5264 EARMOLD 3 3 5.648924 $101.6800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 59 337.464286 $24108.4400 $71.4400
TRAV -TRAVS Travel by mile 549 1057 175462.003145 $78080.5900 $0.4500
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Subtotal (Total Children Is Unduplicated) 584 2972 182486.266446 $531613.1200 $2.9100
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Total 3633 183344.229084 $587669.7100 $3.2100
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Number of Children (Unduplicated) With at Least One Authorization 601