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
Eligibility Filter: Program Patients
With the filters selected there were 3679 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 18.255555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 50 50 9291.000000 $343767.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 64 69 9309.255555 $343767.0000 $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 3 3 2.333334 $268.3400 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 28 33 35.542010 $1777.1100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 38 40 55.744445 $2787.2300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 15 30.000000 $2250.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 16.005479 $1200.4100 $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 218 219 428.044138 $32103.3200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 171 171 326.340810 $24475.5700 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 68 69 131.016437 $9826.2400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 83 84 156.313109 $8675.3800 $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 49 49 13.357148 $681.9100 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 16 16 5.322221 $271.6900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 70 72 35.222226 $1798.1100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 36 37 6.627781 $338.3600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 2.633333 $134.4300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 32 14.166667 $723.2100 $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 168 175 57.232546 $2921.7500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 630 1065 1368.251609 $94015.1900 $68.7100
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.811112 $40.5600 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.900000 $45.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 15 8.286112 $414.3100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.022223 $25.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 269 289 196.122225 $9806.1300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 250 268 310.741272 $7768.5400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 159 297 158.955565 $7947.8300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 95 167 164.466667 $4111.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 71 55.200006 $2760.0300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 45 64.638887 $1615.9700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 233 242 164.677778 $8233.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 225 234 254.847620 $6371.1900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 38.142857 $953.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 323 346 2298.688881 $114934.4900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 123 133 607.160316 $43375.5700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 129 137 796.107144 $45537.3100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 45 49 263.811903 $18846.7400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 34 39 263.750001 $15075.9400 $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 3 3 2.611112 $47.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 193 1204.249992 $86031.6400 $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) 608 2545 6872.318657 $375337.7400 $54.6200
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Total 3679 17549.825821 $813119.9300 $46.3300
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Number of Children (Unduplicated) With at Least One Authorization 920