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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2854 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 57 59 2035.399998 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 39 39 12498.200000 $464933.0400 $37.2000
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Subtotal (Total Children Is Unduplicated) 95 98 14533.599998 $464933.0400 $31.9900
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.366667 $26.6600 $19.5100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.488889 $22.1600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.311111 $151.8400 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 24 28 43.124353 $2156.2200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 4 1.574276 $78.7200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 9 9 16.300000 $815.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 4 6.577778 $493.3400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 19 36.005479 $2700.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 338 338 670.066667 $50255.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 56 56 112.000000 $8400.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 42 42 84.000000 $6300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 92 92 182.000000 $13650.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 12 12 22.000000 $1650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 209 209 416.066667 $23091.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 70.000000 $3885.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 62 65 18.908729 $972.0900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 1.850000 $95.1100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 4.511111 $231.9200 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 60 60 42.877092 $2204.3100 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 2.294444 $117.9600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 4 4 6.000000 $308.4600 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 35 36 8.911110 $458.1100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.738889 $37.9900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 2.934920 $150.8800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 19 13.050000 $670.9000 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 0.200000 $10.2800 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 14 7.005556 $360.1600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 121 130 50.195239 $2580.5400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.372222 $19.1300 $51.4100
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Subtotal (Total Children Is Unduplicated) 711 1247 1889.736678 $126653.5200 $67.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 0.777777 $3888.5000 $4999.5000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.466667 $23.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.644445 $380.9000 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 22 13.638892 $681.9600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 3.033334 $75.8400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 172 187 98.772218 $4938.5900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.511111 $25.5600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 79 85 103.093653 $2577.3500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 160 71.449998 $3572.4900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 2 1.644444 $82.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 31 61 49.444436 $1236.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 63 30.200003 $1510.0200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 14 27 27.050001 $676.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 153 164 90.844443 $4542.2200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.422222 $21.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 77 82 90.500003 $2262.5100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 14.142858 $707.1400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 202 1333.733327 $66686.6900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 9 48.857143 $2442.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 78 84 495.152381 $35631.1500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.714286 $123.3600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 83 91 818.330158 $47135.8200 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 34.285714 $1974.8600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 43 47 329.719049 $23726.5900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 35 39 316.714284 $18230.0800 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 1.785714 $102.7800 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 5.714286 $328.9200 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.311111 $71.4300 $229.6000
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.488889 $341.8700 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 2 2 1.522223 $27.6000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 126 143 909.846032 $65472.5300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 11.142857 $801.8400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 5 5 27.523808 $1980.6100 $71.9600
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Subtotal (Total Children Is Unduplicated) 447 1509 4941.477767 $293399.4800 $59.3700
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Total 2854 21364.814443 $884986.0500 $41.4200
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Number of Children (Unduplicated) With at Least One Authorization 917