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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2644 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 17 17 14.655555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 44 45 11874.855555 $439369.6500 $37.0000
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Subtotal (Total Children Is Unduplicated) 60 62 11889.511110 $439369.6500 $36.9500
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.555556 $25.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.277778 $31.9500 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 40 47 40.418948 $2020.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 36 36 62.790411 $3139.5300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 16.005479 $1200.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.005479 $333.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 189 189 376.005479 $28200.4100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 167 167 322.032874 $24152.4800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 28 28 56.000000 $4200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 65 66 114.049311 $6329.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 55 55 106.010958 $7950.8300 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 61 62 12.588895 $642.6900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 15 17 5.155555 $263.1900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 41 43 23.084572 $1178.4600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 41 42 9.088895 $464.0200 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.127778 $6.5200 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 2.133333 $108.9000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 20 21 7.243608 $369.7900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.233334 $11.9200 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 97 102 25.461112 $1299.7900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 5 0.816666 $39.9600 $48.9400
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Subtotal (Total Children Is Unduplicated) 521 917 1214.086021 $84069.8600 $69.2500
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.555556 $27.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.611111 $30.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.611111 $140.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 9 5.044444 $252.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.327778 $8.2000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 176 191 140.572218 $7028.5900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 155 169 223.354762 $5583.8700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 194 149.905551 $7495.2600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 61 96 95.383331 $2384.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 67 39.244446 $1962.2300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 40 43.777781 $1094.4500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 155 169 121.022221 $6051.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 138 149 187.838886 $4695.9700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 12.571429 $314.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 201 221 1470.061909 $73503.1000 $50.0000
INTR -T1013 INTERPRETER 2 2 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 62 63 305.546031 $21828.1900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 76 81 530.670232 $30354.3600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 41 43 240.590474 $17187.7900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 28 32 162.569048 $9292.4400 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.555556 $709.3500 $456.0100
SENS -V5264 EARMOLD 2 2 1.777778 $32.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 129 799.690474 $57129.9100 $71.4400
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Subtotal (Total Children Is Unduplicated) 409 1665 4537.567841 $247321.0500 $54.5100
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Total 2644 17641.164972 $770760.5700 $43.6900
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Number of Children (Unduplicated) With at Least One Authorization 712