Summary Report for FSPSAs Initiated During the Report Period Center: 07
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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1019 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 4 4 14.400795 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 14.400795 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 0.715068 $6.2600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 0.715068 $15.6200 $21.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 0.715068 $16.3800 $22.9000
EXIT -EXIT EXIT ASSESSMENT 24 24 9.700838 $485.0400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.068493 $5.1400 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.068493 $114.8000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 27 27 34.054790 $2554.1300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 0.161644 $12.1200 $74.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 43 43 32.947944 $1828.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 2.649316 $198.7000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.000000 $51.0500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.100000 $5.1100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 2 0.155556 $7.9400 $51.0600
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 2.692314 $137.4400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 1.066667 $54.4600 $51.0500
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Subtotal (Total Children Is Unduplicated) 100 155 92.816738 $5745.2900 $61.9000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.496043 $24.8000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 86 95 40.223615 $2011.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 3.677777 $91.9400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 121 184 493.454418 $24672.7300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 8 12.400000 $310.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 21.623809 $1081.2000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 11.280953 $564.0500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 24.409524 $1220.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.600000 $40.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 441 481 3603.519057 $180175.8500 $50.0000
INTR -T1013 INTERPRETER 5 5 45.714285 $2285.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 12.714286 $908.3100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 49.714285 $3551.5900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 23 143.714285 $10266.9600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 8.285715 $115.0100 $13.8800
TRAV -TRAVS Travel by mile 30 35 229.966664 $102.3300 $0.4400
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Subtotal (Total Children Is Unduplicated) 465 860 4702.794716 $227422.1600 $48.3600
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Total 1019 4810.012249 $233167.4500 $48.4800
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Number of Children (Unduplicated) With at Least One Authorization 492