Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1145 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 16 18 21.225398 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 16 18 21.225398 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 6 2.422222 $117.4800 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 4.055555 $207.0300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 6 1.422223 $72.6100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 8.144446 $415.7800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.116667 $5.7100 $48.9500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 30 37 16.161113 $818.6100 $50.6500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 121 23.972214 $1198.5700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 7 5.455557 $272.7900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 5.357143 $267.8600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 6 5.100001 $255.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.355556 $17.7800 $50.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 109 112 853.000004 $42650.0400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 729 815 6413.115923 $64131.1800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 92.857142 $6633.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.571429 $833.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 3 4 18.571429 $1326.7300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 6.857143 $391.9500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 27.000001 $1928.8800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 27.857143 $386.6600 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 782 1090 7497.070685 $120998.6500 $16.1400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1145 7534.457196 $121817.2600 $16.1700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 800