Summary Report for FSPSAs Initiated During the Report Period Center: 55
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 3807 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 56.433334 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 58 58 10747.733333 $397666.1300 $37.0000
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Subtotal (Total Children Is Unduplicated) 75 79 10804.166667 $397666.1300 $36.8100
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.466667 $21.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.666666 $76.6600 $114.9900
EVAL -96111 DEVELOPMENTAL EVALUATION 43 52 47.742313 $2387.1200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 44 45 74.935616 $3746.7900 $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 263 263 516.164773 $38712.3700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 234 234 451.324067 $33849.3200 $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 81 82 139.345983 $7733.7100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 72 72 138.153815 $10361.5400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 80 85 21.907944 $1118.4400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 21 22 9.122223 $465.6900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 64 67 30.105555 $1536.8900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 38 40 8.688893 $443.5900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 1.516667 $77.4300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 30 32 12.033334 $614.3100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.177778 $9.0800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 157 173 50.708741 $2588.7400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 0.238889 $11.6900 $48.9400
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Subtotal (Total Children Is Unduplicated) 669 1259 1645.355020 $114252.3900 $69.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.224658 $6123.5000 $5000.1700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.700000 $35.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.955556 $47.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.855556 $196.7900 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 11 7.172222 $358.6100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 1.605556 $40.1400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 251 272 163.188881 $8159.4100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 228 242 223.315871 $5582.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 173 310 222.227763 $11111.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 95 155 178.522219 $4463.0500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 88 59.163484 $2958.1400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 43 50.912698 $1272.8200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 222 233 136.122220 $6806.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 210 218 187.055554 $4676.3900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 9 81.285715 $2032.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 308 325 1774.384175 $88719.1300 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 110 111 432.831755 $30921.4800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 129 138 849.319063 $48581.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 41 41 271.973812 $19429.7900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 40 43 265.464289 $15173.9300 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.466667 $1124.8200 $456.0100
SENS -V5264 EARMOLD 4 4 2.611111 $47.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 194 207 1193.607166 $85271.1800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 19.142858 $265.7000 $13.8800
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Subtotal (Total Children Is Unduplicated) 625 2469 6129.108849 $343726.0900 $56.0800
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Total 3807 18578.630536 $855644.6100 $46.0600
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Number of Children (Unduplicated) With at Least One Authorization 846