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
Eligibility Filter: Program Patients
With the filters selected there were 2228 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 35 35 40.120633 $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) 36 36 40.987300 $32.0700 $0.7800
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.733333 $34.5300 $47.0900
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 3.146576 $376.3300 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 9 12 2.623209 $131.1700 $50.0000
EXIT -EXIT EXIT ASSESSMENT 13 13 3.436986 $171.8500 $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 232 232 115.315969 $8648.9600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 129 129 55.563165 $4167.3900 $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 1.901903 $97.0900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 24 29 5.657189 $288.8100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 14 1.743379 $89.0000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 16 7.373406 $376.4200 $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 25 12.363285 $631.1400 $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) 351 660 326.303831 $23032.4700 $70.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 0.391781 $1958.5000 $4998.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.555555 $77.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.466667 $73.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.766666 $183.3700 $239.1800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 9 3.232575 $161.6400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 8 7.511111 $187.7800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 136 124.669843 $6233.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 123 130 379.919051 $9497.9900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 90 80.134923 $4006.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 26 37 39.915873 $997.9000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 41 20.636509 $1031.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 10 11.273015 $281.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 111 123 111.892065 $5594.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 123 142 395.510319 $9887.7700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 22.857143 $571.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 218 231 1412.514265 $70625.7300 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 94 108 558.692530 $39913.0000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 94 103 604.142853 $34557.0000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 77 81 498.434521 $35608.1600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 41 45 228.547620 $13063.7600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.224658 $53.2800 $237.1600
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.361644 $85.7400 $237.0900
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 1.000000 $474.2400 $474.2400
SENS -V5264 EARMOLD 7 7 13.973015 $251.5100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 192 210 1224.097621 $87449.5200 $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) 501 1532 5754.150394 $323172.8700 $56.1600
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Total 2228 6121.441525 $346237.4100 $56.5600
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Number of Children (Unduplicated) With at Least One Authorization 658