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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2637 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 16 16 34.027778 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 54 55 5251.933333 $194321.5300 $37.0000
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Subtotal (Total Children Is Unduplicated) 67 71 5285.961111 $194321.5300 $36.7600
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.555555 $63.8800 $114.9900
EVAL -96111 DEVELOPMENTAL EVALUATION 23 25 32.792922 $1639.6500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 52 52 92.344444 $4617.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 8.005479 $600.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.005479 $111.3100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 34 34 68.000000 $5100.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 208 209 416.285714 $31221.4300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 44.000000 $3300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 41 42 80.209524 $6015.7200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 87 90 178.285714 $13371.4300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 26 52.000000 $2886.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 96 96 192.000000 $10656.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 13 18 36.000000 $2700.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 55 63 31.490475 $1607.5900 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.100000 $56.1600 $51.0500
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.188889 $9.6400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 6.205556 $316.8000 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 68 70 49.967079 $2550.8200 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 38 39 12.644447 $645.5100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 2.344444 $119.6800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 28 17.566667 $896.7800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.744444 $38.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 131 134 56.191272 $2868.5800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 2.194443 $112.0200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 0.794445 $35.4000 $44.5500
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Subtotal (Total Children Is Unduplicated) 568 1018 1443.094770 $95506.1400 $66.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.888889 $44.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 5.000000 $250.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.777779 $69.4500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 148 155 104.540480 $5227.0400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 112 117 123.055553 $3076.3800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 97 187 105.419050 $5270.9700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.188889 $9.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 50 92 96.377779 $2409.4500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 55 33.922220 $1696.1000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 42 49.277779 $1231.9500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 126 81.161114 $4058.0700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 110 113 114.366666 $2859.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 11.607143 $290.1800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 173 176 1265.423799 $63271.2500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 14 82.642857 $4132.1500 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 89 96 536.928567 $38358.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 108 117 981.799999 $56158.9800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 34.428572 $1969.3200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 35 39 204.428568 $14604.3900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 40 41 391.571432 $22382.2000 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 2 3.000000 $684.0000 $228.0000
SENS -V5264 EARMOLD 3 3 2.044444 $36.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 141 145 1129.678562 $80704.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 11.357142 $811.3500 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 43.714286 $3122.9500 $71.4400
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Subtotal (Total Children Is Unduplicated) 441 1548 5420.990458 $318307.9800 $58.7200
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Total 2637 12150.046339 $608135.6500 $50.0500
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Number of Children (Unduplicated) With at Least One Authorization 696