Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 2192 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 9 9 11.555555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 11.555555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 18 44.100794 $3307.5700 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 9.005479 $675.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 3.005479 $225.4100 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 8 8 12.005479 $900.4100 $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 64 64 102.763471 $5703.3800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 10 10 10.016438 $555.9100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 45 45 80.000000 $6000.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 76 76 122.172753 $9162.9600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 28 28 52.000000 $3900.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 19 19 25.008219 $1875.6200 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 100 101 163.164383 $12237.3200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 77 79 133.010958 $7382.1100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 48 48 79.021917 $4385.7200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.005479 $0.4100 $75.2900
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 5 1.466666 $74.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 38 40.873114 $2086.5800 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 1.950000 $99.5500 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.005556 $0.2900 $51.4600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 2.205555 $112.5900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 19 8.635541 $440.8500 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 3 3 0.235769 $12.0400 $51.0600
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $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 55 55 24.695358 $1260.7100 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.883333 $147.1900 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 3.843075 $196.1900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 1.094444 $55.8700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 7 7 4.385161 $195.3600 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.511720 $67.3500 $44.5500
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Subtotal (Total Children Is Unduplicated) 342 672 950.066141 $62564.8200 $65.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 8.079452 $40397.5000 $5000.0300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 30 25.902415 $1295.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 24 28 31.409524 $1570.4800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 261 273 319.272471 $15963.6800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 44 45 46.641274 $2332.0800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 89 91 106.390477 $5319.5300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 13 14 24.881745 $1244.0900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.884127 $122.1100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 88 90 104.305006 $5215.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 22 22 23.696826 $1184.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.516667 $12.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 196 201 228.086515 $11404.3700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 38 39 48.745240 $2437.2800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 2.633333 $65.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 286 298 2001.523777 $100076.3200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 62 64 422.619756 $21131.0200 $50.0000
INTR -T1013 INTERPRETER 1 1 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 62 63 368.190478 $26303.5100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 4.000000 $285.7600 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 7.142857 $510.2900 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 7 7 38.463492 $2747.8300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 59 63 397.916664 $28427.1800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 18.857143 $1347.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 33.285714 $1902.6100 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 23.314286 $1665.5700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 7 7 59.285714 $4235.3600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 111 659.186151 $47092.3300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 11 40.096476 $2864.5100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 26.000000 $1857.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 12 12 91.352381 $6526.2200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 31.285714 $434.2500 $13.8800
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Subtotal (Total Children Is Unduplicated) 388 1511 5205.394246 $336343.8700 $64.6100
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Total 2192 6167.015942 $398908.6800 $64.6800
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Number of Children (Unduplicated) With at Least One Authorization 517