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
Eligibility Filter: Program Patients
With the filters selected there were 3410 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 14.655555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 39 41 7290.819047 $269760.3000 $37.0000
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Subtotal (Total Children Is Unduplicated) 56 62 7305.474602 $269760.3000 $36.9300
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 30 38 21.145887 $1057.3000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 44 62.743150 $3137.1500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 22.011111 $1650.8300 $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 8 8 12.016590 $666.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 271 272 528.043832 $39603.3000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 222 224 432.043832 $32403.3000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 87 87 160.038353 $12002.8900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 90 91 168.038353 $9326.1400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 40.000000 $3000.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 60 66 14.072220 $718.3800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 27 28 9.066666 $462.8500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 60 60 33.227778 $1696.2800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 36 36 5.911113 $301.7700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 1.211111 $61.8300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 35 38 14.261112 $728.0300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 162 168 49.065077 $2504.7600 $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) 706 1220 1599.714829 $111329.7600 $69.5900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.128767 $15644.0000 $5000.0500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.033333 $51.6700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.522222 $120.1100 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 10 4.116669 $205.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.788889 $69.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 216 153.283327 $7664.1400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 192 207 227.377778 $5684.4500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 133 248 155.099985 $7754.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 76 129 160.166663 $4004.1600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 88 61.549998 $3077.4900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 49 57.490476 $1437.2600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 183 125.855556 $6292.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 175 188 195.955557 $4898.8900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 44.000000 $1100.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 246 263 1771.404778 $88570.2200 $50.0000
INTR -T1013 INTERPRETER 1 1 12.571429 $628.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 108 111 452.314282 $32313.3500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 119 134 869.071435 $49710.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 48 55 285.457143 $20393.0600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 39 41 258.892856 $14798.3500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 4.000000 $1824.0000 $456.0000
SENS -V5264 EARMOLD 3 3 3.511110 $63.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 173 183 1169.285714 $83533.7800 $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) 532 2128 6020.306538 $349922.5500 $58.1200
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Total 3410 14925.495969 $731012.6100 $48.9800
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Number of Children (Unduplicated) With at Least One Authorization 938