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
Eligibility Filter: Program Patients
With the filters selected there were 1451 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 31 33 19.277780 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 31 33 19.277780 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 14 18 3.137212 $156.8700 $50.0000
EXIT -EXIT EXIT ASSESSMENT 13 13 11.175344 $558.7700 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 17 17 30.010958 $2250.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 10 10 16.010958 $1200.8300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 18 18 32.010958 $2400.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 6.016437 $333.9200 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 12 12 2.116666 $108.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.087671 $4.4800 $51.0700
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 7 1.877778 $95.8600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 1.599999 $81.6700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.572222 $29.2100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.600000 $30.6300 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.844444 $43.1100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 28 28 9.578299 $488.9700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 0.477778 $24.3900 $51.0500
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Subtotal (Total Children Is Unduplicated) 107 146 116.116724 $7808.4000 $67.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 125.210959 $626055.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.133333 $6.6700 $49.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.133333 $30.6600 $229.9400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 15 3.061722 $153.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.200000 $30.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 152 185 108.077779 $5403.9000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 137 162 175.438893 $4385.9800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 208 105.194437 $5259.6900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 82 72.099995 $1802.4900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 97 52.196826 $2609.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 49 54.888888 $1372.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 125 75.616668 $3780.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 109 125 138.943654 $3473.6000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 20.285714 $507.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 59 67 314.997618 $15749.8800 $50.0000
INTR -T1013 INTERPRETER 1 1 0.900000 $45.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 222.714285 $15910.7000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 19 21 144.321431 $8255.1800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 17 17 89.788096 $6414.4500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 13 72.000000 $4115.5300 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.133333 $2.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 53 333.928571 $23855.8400 $71.4400
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Subtotal (Total Children Is Unduplicated) 357 1272 2112.265535 $729676.0900 $345.4500
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Total 1451 2247.660039 $737484.4900 $328.1100
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Number of Children (Unduplicated) With at Least One Authorization 428