Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 899 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 5.666666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 5.666666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 3 3 3.000000 $150.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 44 50 39.471787 $1973.5900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.500000 $112.5000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 2.508219 $188.1200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 3.008220 $225.6100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 21 21 13.582193 $753.8100 $55.5000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 1.145205 $58.4600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 80 88 66.715624 $3625.6300 $54.3400
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 19 26.223811 $1311.2000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 242 265 360.738887 $18036.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.700000 $67.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 64 71 125.420236 $6271.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 98 102 137.290190 $6864.4900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 186 261.443707 $13072.2100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.733334 $168.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 15 63.695240 $1592.3800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 100 112 608.461904 $30423.0600 $50.0000
INTR -T1013 INTERPRETER 8 8 42.071430 $2103.5600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 19.785715 $1413.4900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 33.857144 $2418.7500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 10 82.571429 $5898.9000 $71.4400
TRAV -TRAVS Travel by mile 9 9 268.314286 $119.4000 $0.4500
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Subtotal (Total Children Is Unduplicated) 301 808 2039.307313 $89761.2300 $44.0200
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Total 899 2111.689603 $93386.8600 $44.2200
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Number of Children (Unduplicated) With at Least One Authorization 351