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 1946 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 17 17 14.622222 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 1594.000000 $58978.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 21 22 1608.622222 $58978.0000 $36.6600
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 24 28 27.364232 $1368.2200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 37 38 52.744445 $2637.2300 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 18 18 36.000000 $2700.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 16 16 30.285714 $2271.4300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 18.291193 $1015.1600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 6 0.977778 $49.9200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.366667 $18.7200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 3.105557 $158.5500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.216667 $11.0600 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.561112 $28.6500 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 4.983335 $254.4100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.377778 $16.8300 $44.5500
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Subtotal (Total Children Is Unduplicated) 118 157 197.530034 $12209.5600 $61.8100
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 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 2 2 9.142857 $228.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 71 80 483.976189 $24198.8200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 68.000000 $4857.9200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 12 13 71.000001 $4061.1900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 5 16.142858 $1153.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 9.000000 $514.4400 $57.1600
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 19 19 135.857143 $9705.6300 $71.4400
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Subtotal (Total Children Is Unduplicated) 441 1767 2174.144071 $94048.0800 $43.2600
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Total 1946 3980.296327 $165235.6400 $41.5100
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Number of Children (Unduplicated) With at Least One Authorization 517