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
Eligibility Filter: Program Patients
With the filters selected there were 3635 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 20 20 22.592064 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 49 49 9787.300000 $362130.1000 $37.0000
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Subtotal (Total Children Is Unduplicated) 64 69 9809.892064 $362130.1000 $36.9100
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 29 34 38.349240 $1917.4800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 65 66 112.000001 $5600.0100 $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 220 221 432.044138 $32403.3200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 172 172 328.340810 $24625.5700 $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 15 15 30.000000 $2250.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 45 47 13.855730 $707.3400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 12 3.122222 $159.3900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 73 76 43.717463 $2231.7900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 30 32 5.716669 $291.8500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 1.172223 $59.8500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 35 36 21.155557 $1080.0000 $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 180 188 53.294455 $2720.7400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.983334 $43.8100 $44.5500
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Subtotal (Total Children Is Unduplicated) 615 1098 1436.336792 $97405.3800 $67.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 0.677778 $3389.0000 $5000.1600
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 16 17 15.509921 $775.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.716667 $17.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 235 247 179.142058 $8957.0800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 221 241 257.577784 $6439.4500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 141 259 141.199997 $7059.9900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 89 158 155.577782 $3889.4600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 61 31.905552 $1595.2600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 42 33.211111 $830.2800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 210 219 154.108725 $7705.4100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 216 229 239.350799 $5983.7800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 42.428571 $1060.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 279 293 1928.585735 $96429.2300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 65 66 61.142855 $3057.1600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 85 88 434.321432 $31027.9200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 11 11 15.999999 $1143.0300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 115 124 808.909523 $46269.6200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 17 17 16.428571 $939.7200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 36 41 256.500002 $18324.3500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 8 8 7.000000 $500.0800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 31 34 223.678567 $12785.4800 $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 184 202 1249.214293 $89243.7800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 31 32 32.428572 $2316.7100 $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 43 53 50.485712 $1868.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 592 2468 6363.335341 $353266.3000 $55.5200
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Total 3635 17609.564197 $812801.7800 $46.1600
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Number of Children (Unduplicated) With at Least One Authorization 807