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 1102 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
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Subtotal (Total Children Is Unduplicated) 35 35 40.120633 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.446576 $53.4100 $119.6100
EVAL -96111 DEVELOPMENTAL EVALUATION 7 9 2.445584 $122.2800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 13 13 3.436986 $171.8500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 12.010958 $900.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 10.010958 $750.8300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 2.016437 $151.2400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 0.688889 $35.1700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 11 11 1.053807 $53.8000 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 0.421613 $21.5200 $51.0400
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 4 0.392009 $20.0200 $51.0600
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.136987 $6.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 1.104490 $56.3800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 0.076985 $3.9300 $51.0600
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Subtotal (Total Children Is Unduplicated) 61 81 38.253237 $2570.9600 $67.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 0.391781 $1958.5000 $4998.9700
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 25 39 20.269843 $1013.5000 $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 2 2 18.000000 $450.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 64 68 382.664280 $19133.2200 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 33 175.362697 $12527.9000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 22 25 154.892854 $8859.8900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 27 27 172.610715 $12331.3000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 11 12 49.571429 $2833.5000 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.224658 $53.2800 $237.1600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 1.000000 $474.2400 $474.2400
SENS -V5264 EARMOLD 2 2 1.811111 $32.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 83 477.321426 $34099.8500 $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 1 1 0.714286 $9.9100 $13.8800
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Subtotal (Total Children Is Unduplicated) 329 986 2614.179569 $130901.0000 $50.0700
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Total 1102 2692.553439 $133471.9500 $49.5700
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Number of Children (Unduplicated) With at Least One Authorization 378