Summary Report for FSPSAs Ending During the Report Period Center: 55
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 2598 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 37 37 152.776192 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 30 30 3108.000000 $114996.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 66 67 3260.776192 $114996.0000 $35.2700
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 27 30 33.038812 $1651.9400 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 45 83.142857 $4157.1500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 9 16.011111 $1200.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 6.011111 $333.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 32 32 64.000000 $4800.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 266 268 554.000000 $41550.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 34 34 68.000000 $5100.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 106 108 216.000000 $16200.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 28.000000 $2100.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 51 51 120.000000 $9000.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 41 42 83.000000 $4606.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 69 71 142.000000 $7881.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 46 49 13.542860 $691.3800 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 3 3 0.683333 $34.8800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 2.483333 $126.7700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 49 49 23.761109 $1212.9900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 19 19 3.809524 $194.4800 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.094444 $4.8200 $51.0300
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.033333 $1.7000 $51.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 28 29 17.522223 $894.5100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 2.394444 $122.2300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 101 103 44.215021 $2257.1500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 5.527776 $282.1800 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.438889 $22.4100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.016666 $102.9500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 0.627778 $27.9700 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.100000 $4.4600 $44.5500
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Subtotal (Total Children Is Unduplicated) 576 1008 1562.454624 $106716.1200 $68.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 2.966666 $14833.0000 $4999.8900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.811111 $186.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 9 3.883332 $194.1600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 6 5.000000 $250.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 5 1.722224 $43.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 164 171 113.855556 $5692.7800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.200000 $10.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 140 148 139.461108 $3486.5200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 84 146 90.992853 $4549.6300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.238889 $11.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 49 80 73.479372 $1837.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 47 22.822225 $1141.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 38 39.616666 $990.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 139 146 98.233335 $4911.6800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.788889 $39.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 133 140 123.222221 $3080.5500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.071429 $26.7900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 202 1444.103173 $72205.1600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 35.285715 $1764.2900 $50.0000
INTR -T1013 INTERPRETER 2 3 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 73 476.971428 $34074.8300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 28.285714 $2020.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 60 63 508.242861 $29071.4700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 41.000001 $2345.1900 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.857143 $275.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 22 22 131.714285 $9409.6600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 33 34 274.249998 $15676.1200 $57.1600
SENS -V5264 EARMOLD 1 1 1.622222 $29.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 130 139 1015.071430 $72516.6900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 18.428571 $1316.5300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 12 12 86.142857 $6154.0600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 4 16.714286 $1194.0700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 17.428571 $241.9100 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 4.000000 $148.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 407 1523 4827.769845 $290042.3800 $60.0800
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Total 2598 9651.000661 $511754.5000 $53.0300
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Number of Children (Unduplicated) With at Least One Authorization 785