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
Eligibility Filter: Program Patients
With the filters selected there were 3490 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 21 21 48.033332 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 52 53 13504.855555 $499679.6500 $37.0000
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Subtotal (Total Children Is Unduplicated) 72 74 13552.888887 $499679.6500 $36.8700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.112329 $5.4500 $48.4900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.010351 $45.4700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.922222 $336.0500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 48 57 51.074581 $2553.7400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 44 76.864384 $3843.2300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 30.011111 $2250.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 13 13 22.016590 $1651.2500 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $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 5 5 8.005479 $444.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 265 265 520.164773 $39012.3700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 233 233 449.324067 $33699.3200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 40 40 72.021916 $5401.6500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 82 83 141.345983 $7844.7100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 70 70 134.153815 $10061.5400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 81 84 16.669056 $851.0000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.216667 $11.0600 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 16 18 6.155555 $314.2400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 45 48 25.895684 $1321.9800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 59 61 12.566672 $641.5600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.127778 $6.5200 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 2.427777 $123.9300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 22 23 7.732497 $394.7500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.205556 $10.5000 $51.0600
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 0.327778 $16.7300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 129 135 33.727781 $1721.8200 $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) 692 1223 1625.897068 $113353.9500 $69.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.005479 $10027.5000 $5000.0500
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.355556 $67.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.700000 $85.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.777778 $178.8900 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 11 6.088888 $304.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.611111 $15.2800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 222 243 174.655555 $8732.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 195 214 256.654765 $6416.3800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 144 254 184.011105 $9200.5300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 81 127 128.702379 $3217.5600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 90 53.222224 $2661.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 31 52 55.055560 $1376.4000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 192 210 148.400000 $7420.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 168 182 210.805554 $5270.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 40.285715 $1007.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 266 293 1915.928580 $95796.4200 $50.0000
INTR -T1013 INTERPRETER 2 2 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 84 85 396.403175 $28319.0300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 102 112 744.277374 $42572.6900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 60 62 325.750791 $23271.6300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 38 44 220.926191 $12628.1400 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 4.010351 $1828.7400 $456.0100
SENS -V5264 EARMOLD 5 5 4.755555 $85.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 164 184 1145.426192 $81829.2600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.285714 $3.9700 $13.8800
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Subtotal (Total Children Is Unduplicated) 561 2193 6026.381306 $342530.6700 $56.8400
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Total 3490 21205.167261 $955564.2800 $45.0600
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Number of Children (Unduplicated) With at Least One Authorization 963