Summary Report for FSPSAs Initiated During the Report Period Center: 55
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 2712 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 17.214286 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 34 34 5987.300000 $221530.1000 $37.0000
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Subtotal (Total Children Is Unduplicated) 45 49 6004.514286 $221530.1000 $36.8900
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.455556 $52.3900 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 21.804948 $1090.2600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 44 44 74.155556 $3707.7800 $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 155 156 308.027701 $23102.0800 $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 8 8 16.000000 $1200.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 33 34 10.746827 $548.6400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 10 2.783333 $142.0900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 60 61 33.283336 $1699.1300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 20 22 3.533335 $180.3900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 0.966667 $49.3500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 31 32 18.466668 $942.7300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.333334 $17.0200 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 135 143 37.788898 $1929.1700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.427778 $19.0600 $44.5500
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Subtotal (Total Children Is Unduplicated) 454 806 1034.311984 $70085.2400 $67.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.344444 $1722.0000 $4999.3600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.455556 $22.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.466667 $23.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.466667 $107.3400 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 13 14.204365 $710.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.716667 $17.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 191 199 146.203172 $7310.1500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 175 189 208.998420 $5224.9700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 189 109.788883 $5489.4200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 66 116 118.788894 $2969.7400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 47 26.055553 $1302.7700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 29 22.288889 $557.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 170 178 125.069838 $6253.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 168 180 195.962705 $4899.0800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 29.000000 $725.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 215 227 1484.571446 $74228.5300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 54 55 51.285712 $2564.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 61 64 342.464288 $24465.6500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 9 12.857142 $918.5100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 81 89 592.480953 $33889.8900 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 8 8 5.571428 $318.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 25 28 173.821430 $12417.7900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 3.000000 $214.3200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 24 25 157.821426 $9021.0800 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 2.857143 $163.3200 $57.1600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 1.714286 $97.9900 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.455556 $207.7500 $456.0400
SENS -V5264 EARMOLD 2 2 1.388889 $25.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 121 133 820.857147 $58641.9900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 19 19 18.000000 $1285.9300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.142857 $65.3700 $57.2000
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 6.285714 $87.2500 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 26 35 28.485713 $1054.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 441 1857 4715.871850 $257860.0200 $54.6800
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Total 2712 11754.698120 $549475.3600 $46.7500
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Number of Children (Unduplicated) With at Least One Authorization 597