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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2089 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 26 27 15.277780 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 27 15.277780 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.139726 $1.1500 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.139726 $3.5400 $25.3100
EVAL -96111 DEVELOPMENTAL EVALUATION 11 15 2.953878 $147.7000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 8 8 7.087672 $354.3800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 6.010958 $450.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 8.010958 $600.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 162 162 268.419950 $20131.5300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 120 120 214.345983 $16075.9700 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 69 69 97.106841 $7283.0400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 52.032874 $2887.8300 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 37 37 10.566665 $539.4200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.844445 $43.1100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 19 5.323288 $271.7500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 17 18 5.001981 $255.3600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 3.227777 $164.7700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 15 15 6.826332 $348.4900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 57 19.162699 $978.2600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 2.344444 $119.6800 $51.0500
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Subtotal (Total Children Is Unduplicated) 334 586 715.734933 $51039.4200 $71.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.273973 $21370.0000 $5000.0300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.566667 $28.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 2.542315 $127.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.433333 $10.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 119 148 88.505556 $4425.2800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 110 131 153.659527 $3841.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 166 86.583331 $4329.1600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 76 62.444440 $1561.1000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 80 46.438891 $2321.9600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 44 49.255555 $1231.3900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 99 64.772225 $3238.6300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 87 102 122.042066 $3051.0600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 4 21.857143 $546.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 167 194 1152.647622 $57632.3400 $50.0000
INTR -T1013 INTERPRETER 1 1 0.900000 $45.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 86 91 463.267891 $33095.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 81 89 613.750006 $35106.4700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 47 48 227.914287 $16282.1800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 48 52 315.278573 $18021.3200 $57.1600
SENS -V5264 EARMOLD 1 1 0.566667 $10.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 129 872.164292 $62307.4000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 20.428572 $283.5500 $13.8800
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Subtotal (Total Children Is Unduplicated) 364 1476 4370.292932 $268867.0800 $61.5200
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Total 2089 5101.305645 $319906.5000 $62.7100
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Number of Children (Unduplicated) With at Least One Authorization 585