Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 1753 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 32 32 36.076189 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.866667 $32.0700 $37.0000
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Subtotal (Total Children Is Unduplicated) 33 33 36.942856 $32.0700 $0.8700
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.224658 $26.8700 $119.6200
EVAL -96111 DEVELOPMENTAL EVALUATION 7 9 2.445584 $122.2800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 8 8 1.341095 $67.0600 $50.0000
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 174 174 83.305616 $6248.1200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 103 103 41.178829 $3088.5400 $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 9 9 1.757459 $89.7200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 20 4.469212 $228.1600 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 9 9 1.137824 $58.0800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 13 7.039540 $359.3700 $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 19 19 11.569907 $590.6400 $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) 264 496 243.209688 $16900.6700 $69.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.172603 $863.0000 $4999.9100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.033333 $7.9700 $238.9600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 3.229835 $161.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 7.444444 $186.1100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 102 112 102.453178 $5122.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 105 111 309.800003 $7745.0100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 76 51.247621 $2562.3900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 25 35 39.604761 $990.1200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 36 18.922224 $946.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 9 11.006348 $275.1600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 88 99 87.325399 $4366.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 104 123 325.246827 $8131.1800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 14.571429 $364.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 181 191 1204.457125 $60222.8700 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 68 78 421.311579 $30098.4900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 73 80 453.678570 $25950.4400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 61 65 406.073807 $29009.9100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 33 36 196.583332 $11236.6900 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.224658 $53.2800 $237.1600
SENS -V5264 EARMOLD 2 2 0.944444 $17.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 134 145 858.490483 $61330.5300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.285714 $73.5400 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 5.142857 $71.3800 $13.8800
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Subtotal (Total Children Is Unduplicated) 382 1224 4523.250574 $249985.9200 $55.2700
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Total 1753 4803.403118 $266918.6600 $55.5700
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Number of Children (Unduplicated) With at Least One Authorization 508