Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 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 2093 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 40 38.030713 $1844.4900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.172603 $9.7500 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 39 39 41.687671 $2084.3800 $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 65.000000 $4875.0000 $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 127 128 242.049311 $13433.7500 $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 3 3 0.694673 $35.4600 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.155556 $58.9900 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 10.948022 $558.9000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 9.892847 $505.0300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.810807 $41.3900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 2.793532 $142.6100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 12 8.328462 $425.1600 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.200000 $61.2600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 30 30 17.537444 $895.2900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.466667 $23.8300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.405099 $62.6000 $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) 239 453 681.222718 $42276.2200 $62.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 45 51 48.494476 $242472.0000 $4999.9900
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 74 82 75.126754 $3756.3300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 2.406944 $120.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 2.012500 $50.3100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 168 182 310.831313 $15541.5700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.466667 $73.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 92 93 160.185715 $8009.2900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 6.885714 $344.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 18.200000 $910.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 153 156 259.971427 $12998.5700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.366667 $118.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.400000 $35.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 176 182 1144.485692 $57224.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 26.714286 $1335.7100 $50.0000
INTR -T1013 INTERPRETER 12 22 77.587865 $3879.4000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 191 346 1574.886416 $15748.8800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 46 321.381604 $22959.4800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.142857 $10.2100 $71.4600
OCCT -97530HM OT SESSION BY OT ASST 4 4 27.571429 $1577.0800 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.857143 $275.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 40 40 261.806346 $18703.4500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 4 23.428571 $1673.7400 $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 61 61 429.947354 $30715.4400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 14.428571 $1030.7800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 16.857142 $233.9800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 164 322 78413.051808 $34893.8100 $0.4500
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Subtotal (Total Children Is Unduplicated) 254 1640 83233.595261 $475574.3300 $5.7100
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Total 2093 83914.817979 $517850.5500 $6.1700
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Number of Children (Unduplicated) With at Least One Authorization 321