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 1414 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 14 14 11.111111 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 66.000000 $2442.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 15 77.111111 $2442.0000 $31.6700
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.255556 $29.3900 $115.0200
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 20.997718 $1049.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 23 24 36.344445 $1817.2300 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.366667 $18.7200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.172222 $59.8400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.961112 $100.1200 $51.0500
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Subtotal (Total Children Is Unduplicated) 58 70 93.097720 $5436.1900 $58.3900
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 12 14 97.428573 $4871.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 23.428571 $1673.7400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 4 24.285714 $1389.1400 $57.2000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 1 1 0.255556 $4.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 48.714286 $3480.1400 $71.4400
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Subtotal (Total Children Is Unduplicated) 326 1329 1343.204387 $52108.5300 $38.7900
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Total 1414 1513.413218 $59986.7200 $39.6400
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Number of Children (Unduplicated) With at Least One Authorization 364