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 1725 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 18 18 45.288888 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 936.000000 $34632.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 21 21 981.288888 $34632.0000 $35.2900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.112329 $5.4500 $48.4900
EVAL -96111 DEVELOPMENTAL EVALUATION 41 49 44.108674 $2205.4400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 44 76.864384 $3843.2300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 38.005479 $2850.4100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 36.296672 $2722.2500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 4.010958 $300.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 30.302151 $1681.7700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.000000 $600.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 6 1.277778 $65.2300 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.216667 $11.0600 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 4 3.316667 $169.3200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 1.127778 $57.5700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.488889 $24.9600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.094444 $4.8200 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.266667 $64.6700 $51.0500
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Subtotal (Total Children Is Unduplicated) 144 192 253.489537 $15207.0000 $59.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.005479 $5027.5000 $5000.1000
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 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 3 3 21.571429 $539.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 77 480.866670 $24043.3300 $50.0000
INTR -T1013 INTERPRETER 2 2 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 45.857144 $3276.0300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 50.000000 $2860.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 5 5 35.428572 $2531.0100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.142857 $465.4500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 1.222222 $22.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 18 107.821430 $7702.7700 $71.4400
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Subtotal (Total Children Is Unduplicated) 370 1512 1977.186436 $91951.1500 $46.5100
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Total 1725 3211.964861 $141790.1500 $44.1400
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Number of Children (Unduplicated) With at Least One Authorization 476