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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2806 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 15 15 14.111111 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 38 38 7292.000000 $269804.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 49 53 7306.111111 $269804.0000 $36.9300
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.555556 $25.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.533334 $61.3400 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 20.997718 $1049.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 23 24 36.344445 $1817.2300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 14.005479 $1050.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 12.000000 $900.0000 $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 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 154 155 306.027701 $22952.0800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 120 120 228.049617 $17103.7300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 47 47 93.000000 $6975.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 65 66 124.021916 $6883.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 18.000000 $1350.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 36 36 10.840481 $553.4300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 3.577777 $182.6400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 53 55 28.933335 $1477.0600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 17 18 3.361113 $171.5900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 1.333333 $68.0600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 27 27 11.533333 $588.7800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 0.788890 $40.2800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 131 137 45.571432 $2326.4300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.444444 $19.8000 $44.5500
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Subtotal (Total Children Is Unduplicated) 461 774 993.925383 $68068.2700 $68.4800
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.811112 $40.5600 $50.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 6.091667 $304.5900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.955556 $23.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 224 240 166.105556 $8305.2800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 206 219 274.089685 $6852.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 124 231 125.894453 $6294.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 77 136 135.366666 $3384.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 41 33.166672 $1658.3600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 26 45.150002 $1128.7600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 195 203 138.294445 $6914.7300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 182 190 222.165873 $5554.1500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 5 29.000000 $725.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 257 271 1860.141264 $93007.1000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 96 106 494.446029 $35323.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 95 103 579.178570 $33129.0300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 31 169.597617 $12116.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 22 23 186.785714 $10676.6600 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.555556 $253.3500 $456.0400
SENS -V5264 EARMOLD 2 2 0.811112 $14.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 114 135 827.964281 $59149.7800 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 12.000000 $857.2800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.285714 $45.6100 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.285714 $10.5700 $37.0000
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Subtotal (Total Children Is Unduplicated) 456 1979 5313.143258 $285997.8000 $53.8300
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Total 2806 13613.179752 $623870.0700 $45.8300
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Number of Children (Unduplicated) With at Least One Authorization 679