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 1920 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 19 19 53.322223 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 873.000000 $32301.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 22 23 926.322223 $32301.0000 $34.8700
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.233333 $26.8300 $114.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 40 48 43.431962 $2171.6000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 44 45 74.935616 $3746.7900 $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 19 19 36.005479 $2700.4100 $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 18 18 28.302151 $1570.7700 $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 7 8 1.700000 $86.7900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.138889 $7.0900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 4.305555 $219.8000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.361111 $18.4300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.438888 $73.4500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 2.372222 $121.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 142 195 249.532836 $14966.1400 $59.9800
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
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 250 271 161.622214 $8081.0700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 227 241 221.749204 $5543.7200 $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 221 232 134.555553 $6727.7700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 210 218 187.055554 $4676.3900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 46.285715 $1157.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 71 381.700009 $19084.9800 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 52.142858 $3725.0900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 9 10 56.000002 $3203.1900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 24.714285 $1765.5900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 6.142857 $351.1300 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 1 1 0.233333 $4.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 20 103.714289 $7409.3400 $71.4400
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Subtotal (Total Children Is Unduplicated) 438 1702 1900.444473 $88420.1700 $46.5300
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Total 1920 3076.299532 $135687.3100 $44.1100
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Number of Children (Unduplicated) With at Least One Authorization 537