Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2507 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 23 24 484.431745 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 30 30 1902.700000 $70399.9000 $37.0000
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Subtotal (Total Children Is Unduplicated) 53 54 2387.131745 $70399.9000 $29.4900
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.323288 $14.5500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.244444 $28.1100 $114.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 35 38 38.044596 $1902.2300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 2 4.000000 $200.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 50 53 93.142857 $4657.1500 $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 267 269 556.000000 $41700.0000 $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 108 110 220.000000 $16500.0000 $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 68 70 140.000000 $7770.0000 $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 53 54 16.607141 $847.7800 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 7 7 2.405555 $122.8000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 14.169048 $723.3300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 54 55 27.583334 $1408.1300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 26 27 7.022223 $358.4900 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 5 2.350000 $119.9700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.155556 $7.9400 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 24 25 13.461111 $687.1900 $51.0500
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.411111 $20.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 126 131 56.962427 $2907.9300 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 6.000000 $306.3000 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.288889 $14.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 574 1071 1607.354913 $109147.8500 $67.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.450000 $12250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.733333 $36.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.655556 $32.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.400000 $322.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 2.099999 $105.0000 $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 1 1 0.105556 $2.6400 $25.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 129 136 82.766661 $4138.3100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.822222 $41.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 125 130 122.022218 $3050.5500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 126 61.250001 $3062.5100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 33 57 35.044443 $876.1100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 50 26.033334 $1301.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 41 43.633334 $1090.8400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 109 72.561101 $3628.0100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.172222 $8.6100 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 118 121 105.961105 $2649.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.785714 $219.6400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 185 1255.247612 $62762.4300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 5.142857 $257.1500 $50.0000
INTR -T1013 INTERPRETER 1 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 86 88 505.180949 $36090.1300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 12 12 53.357143 $3811.8400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 65 67 440.369050 $25189.1100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 29.571428 $1691.4900 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.857143 $275.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 21 22 155.571427 $11114.0100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 10.285715 $734.8100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 33 34 239.392860 $13683.6900 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 9.571428 $547.1100 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.394521 $317.9500 $228.0000
SENS -V5264 EARMOLD 3 3 2.355555 $42.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 137 145 914.509520 $65332.5600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 45.714286 $3265.8300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 55.857142 $3990.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.428571 $530.7000 $71.4400
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Subtotal (Total Children Is Unduplicated) 409 1382 4310.304006 $262902.6100 $60.9900
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Total 2507 8304.790664 $442450.3600 $53.2800
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Number of Children (Unduplicated) With at Least One Authorization 672