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 1687 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 30 34 25.133835 $1218.9900 $48.5000
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
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.500000 $787.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 43.000000 $2386.5000 $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 8 8 18.500000 $1387.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 10.571429 $539.6700 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.432877 $22.1000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 4.411111 $225.1900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.158904 $8.1100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.500000 $76.5800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.287748 $269.9400 $51.0500
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Subtotal (Total Children Is Unduplicated) 98 138 184.757853 $10353.2200 $56.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 12 9.472147 $47360.5000 $4999.9800
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 185 201 326.497981 $16324.9300 $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 57 66 380.161904 $19008.1200 $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 11 11 75.523810 $5395.4200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 10 78.571429 $5613.1400 $71.4400
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 12 12 72.642856 $5189.6100 $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) 271 1547 92733.901947 $186087.1300 $2.0100
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Total 1687 92928.629642 $196440.3600 $2.1100
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Number of Children (Unduplicated) With at Least One Authorization 299