Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2411 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 2 2 9.969842 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 9.969842 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 41 50 37.457731 $1816.7000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 3 1.172223 $58.6200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 42 42 52.089726 $2604.4900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $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 8 10 20.000000 $1110.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 71 71 131.527395 $9864.5600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 33 33 63.487671 $4761.5800 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 4.005479 $300.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 126 127 240.049311 $13322.7500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 30 30 59.516437 $4463.7400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 6 11.253088 $574.4700 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.161644 $8.2500 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 4 5 4.466667 $228.0300 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 9.480300 $483.9700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 17.299173 $883.1300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 5.769026 $294.5100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 0.380822 $19.4400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 23 12.781887 $652.5200 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 5.052055 $257.9100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 44 45 24.127396 $1231.7000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.136986 $6.9900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 12.069048 $537.6800 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 277 516 736.284065 $45003.6600 $61.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 46 57 46.662503 $233312.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 72 81 68.633897 $3431.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 1.273611 $63.6800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 2.079167 $51.9800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 186 202 327.497981 $16374.9300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 5.500000 $137.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 114 182.461903 $9123.0900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 4.785714 $239.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.066667 $151.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 49.623810 $2481.1900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.766667 $44.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 161 168 253.285714 $12664.2900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.033333 $1.6700 $49.9500
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.766667 $119.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 199 1154.571425 $57728.5800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 7.857143 $392.8600 $50.0000
INTR -T1013 INTERPRETER 13 22 44.402151 $2220.1100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 219 391 1584.524525 $15845.2500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 60 406.995824 $29075.7800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 16.571428 $1183.8700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 5 37.000001 $2116.3900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 45 46 321.842600 $22992.4100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 7 8 56.285714 $4021.0600 $71.4400
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 4.285714 $244.9700 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 75 496.742790 $35487.3100 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 205 415 89576.827994 $39861.6900 $0.4500
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Subtotal (Total Children Is Unduplicated) 287 1893 94667.344943 $490125.5600 $5.1800
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Total 2411 95413.598850 $535129.2200 $5.6100
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Number of Children (Unduplicated) With at Least One Authorization 402