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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2581 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 20 20 13.788888 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 30 32 5310.985714 $196506.4700 $37.0000
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Subtotal (Total Children Is Unduplicated) 46 52 5324.774602 $196506.4700 $36.9000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.252055 $11.3400 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.022222 $117.5500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 26 33 18.918109 $945.9100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 30 31 46.134855 $2306.7400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 20.011111 $1500.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 13 13 20.027701 $1502.0800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 10.016590 $555.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 214 215 418.032874 $31352.4800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 170 171 336.016437 $25201.2400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 73 73 132.038353 $9902.8900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 71 72 136.021916 $7549.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 16 32.000000 $2400.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 40 44 9.777776 $499.1500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 19 20 5.622223 $287.0200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 49 49 26.994444 $1378.0600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 27 27 4.161112 $212.4300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 1.105555 $56.4400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 29 31 12.633335 $644.9400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 119 124 39.565079 $2019.8000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.172222 $8.4300 $48.9300
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Subtotal (Total Children Is Unduplicated) 547 949 1274.696191 $88761.2500 $69.6300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.511111 $25.5600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 4.105557 $205.2900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.800000 $45.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 157 169 122.433326 $6121.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 148 161 185.588889 $4639.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 96 184 113.199987 $5659.9400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 60 100 122.833333 $3070.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 66 49.477778 $2473.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 38 47.612700 $1190.3200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 134 141 96.672222 $4833.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 133 144 156.633335 $3915.8400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 15.571428 $389.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 198 1340.190488 $67009.5100 $50.0000
INTR -T1013 INTERPRETER 1 1 12.571429 $628.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 70 71 262.635713 $18762.6900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 86 98 625.785718 $35794.9500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 37 39 203.544047 $14541.2000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 29 31 196.464283 $11229.9200 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 2 2 2.466666 $44.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 120 739.428570 $52824.7800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.428571 $81.7200 $57.2000
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Subtotal (Total Children Is Unduplicated) 384 1580 4302.955151 $234400.6400 $54.4700
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Total 2581 10902.425944 $519668.3500 $47.6700
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Number of Children (Unduplicated) With at Least One Authorization 711