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
Eligibility Filter: Program Patients
With the filters selected there were 2094 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 16 16 16.422221 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 3.011112 $111.4100 $37.0000
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Subtotal (Total Children Is Unduplicated) 23 23 19.433333 $111.4100 $5.7300
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 13.361318 $1598.0100 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 10 14 2.350453 $117.5300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 11 11 2.327398 $116.3600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 9 6.030135 $452.2700 $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 5 5 4.013698 $301.0300 $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 232 232 113.474873 $8510.8800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 128 128 53.278233 $3996.0200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 97 97 67.861616 $5089.7200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 53 53 32.202723 $1787.2900 $55.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 1.164688 $59.4600 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 25 27 3.259668 $166.4100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 11 1.444445 $73.7400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 6.028505 $307.7600 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.136987 $6.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 23 23 11.451708 $584.6200 $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) 363 652 324.586720 $23550.5800 $72.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 2.267656 $11338.0000 $4999.8800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.322222 $66.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.755556 $180.7400 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 14 8.987747 $449.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 11 15 19.966668 $499.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 107 133 144.322226 $7216.1300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 115 150 448.333336 $11208.3500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 28 25.666668 $1283.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 12 12 34.477778 $861.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 11.366667 $568.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 25.864285 $646.6100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 84 97.045240 $4852.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 89 106 326.934919 $8173.3900 $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 189 201 1175.345238 $58767.3000 $50.0000
INTR -T1013 INTERPRETER 3 3 12.714286 $635.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 117 132 725.612699 $51837.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 71 79 416.490477 $23823.2500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 84 91 463.440477 $33108.1700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 35 42 166.135716 $9496.3200 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.117809 $265.0500 $237.1200
SENS -V5264 EARMOLD 9 9 15.992064 $287.8600 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 260 285 1614.276182 $115323.9100 $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) 529 1419 5761.293058 $341634.5200 $59.3000
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Total 2094 6105.313111 $365296.5100 $59.8300
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Number of Children (Unduplicated) With at Least One Authorization 803