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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1305 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 25 580.227776 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 1156.000000 $42772.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 29 31 1736.227776 $42772.0000 $24.6400
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 22 24 32.286756 $1614.3400 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 4 6.011111 $300.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 66 66 126.000000 $6300.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3100 $55.7000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 28.000000 $2100.0000 $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 6 6 10.066667 $755.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1776.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 6.000000 $450.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 0.983333 $50.2000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.205556 $61.5500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 3.066667 $156.5600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.550000 $28.0800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.316666 $67.2100 $51.0500
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Subtotal (Total Children Is Unduplicated) 136 168 281.492235 $16014.7900 $56.8900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.450000 $7250.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.333333 $116.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.777778 $38.8900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.777778 $178.8900 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 5.000000 $250.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 1.022223 $25.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 152 161 96.084929 $4804.2900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.288889 $64.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 152 165 133.288890 $3332.2300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 172 79.905561 $3995.3100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 64 116 69.094438 $1727.3500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 50 40.449208 $2022.4700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 49 50.866665 $1271.6600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 129 82.983340 $4149.2000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 144 149 117.750003 $2943.7600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 17.821428 $445.5400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 51 53 346.999996 $17350.0100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 9 25.142856 $1257.1500 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 59.428570 $4245.5800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 38.142857 $2181.7700 $57.2000
PHY -97110HM PT SESSION BY PT ASST 1 1 19.428571 $1110.5400 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 2 2 0.777778 $14.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 11 50.714285 $3623.0400 $71.4400
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Subtotal (Total Children Is Unduplicated) 317 1106 1244.918265 $63379.7700 $50.9100
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Total 1305 3262.638276 $122166.5500 $37.4400
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Number of Children (Unduplicated) With at Least One Authorization 416