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 1027 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 22 23 484.288888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 23 484.288888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 33 35 33.874733 $1693.7300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 2 4.000000 $200.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 48 51 89.142857 $4457.1500 $50.0000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 0.011111 $0.6200 $55.4400
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 16.000000 $888.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 5.740476 $293.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.844445 $43.1100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.783333 $39.9900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.150000 $7.6600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 6.146032 $313.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 120 152 210.854098 $11878.2700 $56.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $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
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 32 32 189.999999 $9500.0100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.000000 $50.0000 $50.0000
INTR -T1013 INTERPRETER 1 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 39.000000 $2786.1600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.000000 $71.4400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 20.742858 $1186.4900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 13.428571 $959.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.857143 $220.4700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 15 87.857144 $6276.5000 $71.4400
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Subtotal (Total Children Is Unduplicated) 255 852 930.532514 $51743.8400 $55.6100
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Total 1027 1625.675500 $63622.1100 $39.1400
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Number of Children (Unduplicated) With at Least One Authorization 349