Summary Report for FSPSAs Ending During the Report Period Center: 57
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 2178 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 6 6 4.594445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 4.594445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.133333 $10.2800 $77.1100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.000000 $55.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.000000 $75.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 14 15 7.245237 $369.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 42 45 13.023810 $664.8800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 23 23 13.292064 $678.5600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 35 36 25.113494 $1282.0600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 72 75 46.197618 $2358.3900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 21 21 18.350002 $936.7800 $51.0500
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Subtotal (Total Children Is Unduplicated) 153 219 125.533336 $6440.3900 $51.3000
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.833333 $41.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 112 121 71.519046 $3575.9500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 11.914286 $595.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 353 373 239.896821 $11994.8200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 22.714284 $567.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 89 97 529.527780 $26476.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 604 1178 4459.800023 $44598.0000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 132.928573 $9496.4100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 30 30 166.821431 $11917.7200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 85.071428 $4862.6900 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 39 238.313493 $17025.1200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.428571 $253.3200 $57.2000
TRAV -TRAVS Travel by mile 34 45 23496.730164 $10456.0500 $0.4500
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Subtotal (Total Children Is Unduplicated) 660 1953 29461.499233 $142091.7100 $4.8200
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Total 2178 29591.627014 $148532.0900 $5.0200
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Number of Children (Unduplicated) With at Least One Authorization 691