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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1534 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.222222 $10.7800 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.122222 $10.3700 $84.8200
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.060274 $2.7100 $45.0200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.060274 $6.9300 $115.0500
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.285714 $15.8600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.285714 $21.4300 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 8 2.094444 $106.9200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 21 7.127779 $363.8800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 1.294444 $66.0800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 19 5.707936 $291.3900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 34 38 9.961112 $508.5200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.177778 $8.7000 $48.9500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 63 99 28.399913 $1463.5600 $51.5300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.222222 $1111.0000 $4999.5000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.577777 $28.8900 $49.9900
CONOF -CONOF CONSULT, OT, FACE TO FACE 108 120 79.458724 $3972.9100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 21 11.169047 $558.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 296 324 177.465070 $8873.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.571429 $14.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 18.857142 $471.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 76 89 491.915083 $24595.7400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 606 787 4165.387300 $41653.8900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 17 108.500001 $7751.2400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 19 20 63.428570 $4531.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 11.857143 $677.7500 $57.1600
SENS -V5130 IN EAR BINAURAL HEARING AID
1 1 0.060274 $27.5000 $456.2000
SENS -V5264 EARMOLD 1 1 0.244444 $4.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 21 83.214287 $5944.8200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.857143 $506.6300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.142857 $43.6200 $13.8800
TRAV -TRAVS Travel by mile 16 24 5420.619047 $2412.1800 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 632 1435 10645.547560 $103179.2800 $9.6900
-------------------------------------------------------------------------------------------------------------------------------------
Total 1534 10673.947473 $104642.8400 $9.8000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 648