Summary Report for FSPSAs Ending During the Report Period Center: 55
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: 10-01-16 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 1573 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 14 14 15.944444 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 2.744445 $101.5500 $37.0000
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Subtotal (Total Children Is Unduplicated) 20 20 18.688889 $101.5500 $5.4300
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.047032 $603.6200 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 7 9 2.156619 $107.8400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 0.294520 $14.7200 $49.9800
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 4.019177 $301.4400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 2.010958 $150.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 2.008219 $150.6200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 175 175 83.464520 $6260.0400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 103 103 40.893897 $3067.1700 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 69 69 48.262994 $3619.7900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 44 44 28.164370 $1563.1600 $55.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 7 0.957230 $48.8700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 20 21 2.815603 $143.7400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 7 1.011112 $51.6200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 11 5.668612 $289.3900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.084932 $4.3300 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 16 10.277909 $524.6900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.189314 $9.6600 $51.0500
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Subtotal (Total Children Is Unduplicated) 269 491 241.327018 $17133.5300 $71.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.153425 $767.0000 $4999.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 12 6.818340 $340.9200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 12 11.766668 $294.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 80 96 112.844448 $5642.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 88 109 324.700794 $8117.5300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 22 21.033334 $1051.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 10 10 30.944444 $773.6100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 10.677778 $533.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 25.864285 $646.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 62 65.321430 $3266.0800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 75 91 264.546824 $6613.6800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 14.571428 $364.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 142 150 872.059524 $43603.0100 $50.0000
INTR -T1013 INTERPRETER 3 3 12.714286 $635.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 78 87 496.607144 $35477.6200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 60 67 337.883334 $19326.9300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 69 75 362.440477 $25892.7300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 28 32 135.564286 $7748.8600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.117809 $265.0500 $237.1200
SENS -V5264 EARMOLD 5 5 6.922222 $124.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 187 203 1136.454755 $81188.3600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.142857 $351.3700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 2.142857 $29.7400 $13.8800
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Subtotal (Total Children Is Unduplicated) 402 1062 4259.292749 $243055.6600 $57.0600
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Total 1573 4519.308656 $260290.7400 $57.6000
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Number of Children (Unduplicated) With at Least One Authorization 614