Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 1399 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 5.433333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.100000 $3.7000 $37.0000
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Subtotal (Total Children Is Unduplicated) 4 4 5.533333 $3.7000 $0.6700
Screening, Eval, and Assessment, Class # 02
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 3.000000 $375.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 3.000000 $375.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 3.857143 $192.8600 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 20 16.169254 $825.4500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 7.900000 $403.2900 $51.0500
SCREEN-T1023 SCREENING 40 40 32.712569 $1635.6300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 7.082192 $361.5500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 11.022222 $562.6800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 95 101 87.743380 $4883.5600 $55.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 15 18.174964 $908.7600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.066667 $26.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 206 247 514.733933 $25736.6400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 154 186 425.738813 $21286.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 89 200.722220 $10036.1000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 189 195 431.963488 $21598.1600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 6.995238 $349.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 196 211 1166.077428 $58303.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 83 335.419045 $23962.3400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 22 84.357143 $4825.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 58 61 239.622618 $17118.6200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 26.571429 $1518.8200 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 173 1065.864297 $76145.3000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 21.811905 $302.7500 $13.8800
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Subtotal (Total Children Is Unduplicated) 430 1294 4541.119188 $272119.9300 $59.9200
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Total 1399 4634.395901 $277007.1900 $59.7700
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Number of Children (Unduplicated) With at Least One Authorization 452