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 1338 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 54 56 1617.399998 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 11 11 3164.000000 $117700.8000 $37.2000
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Subtotal (Total Children Is Unduplicated) 65 67 4781.399998 $117700.8000 $24.6200
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 1 1 1.000000 $115.8100 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 22 24 36.952131 $1847.6100 $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 2 2 2.577778 $193.3400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 38 38 75.000000 $5625.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 17 17 34.000000 $2550.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 58 58 116.000000 $6438.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 13 13 26.000000 $1443.0000 $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 8 8 2.605557 $133.9600 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 6.049315 $310.9900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 1.177777 $60.5500 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.366667 $18.8500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.300000 $118.2400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 15 9.982540 $513.2000 $51.4100
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Subtotal (Total Children Is Unduplicated) 177 245 392.741597 $24602.7300 $62.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 0.344444 $1722.0000 $4999.3600
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.488889 $344.8600 $231.6200
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 54 61 367.790474 $18389.5500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 14.428571 $721.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 13 65.771429 $4732.9100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 14 16 119.571429 $6887.3100 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 15 18 116.190476 $8361.0800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 9 62.857142 $3618.0600 $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 -V5060 BEHIND EAR HEARING AID 2 2 1.488889 $341.8700 $229.6100
SENS -V5264 EARMOLD 1 1 1.366667 $24.7800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 28 172.285714 $12397.6800 $71.9600
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Subtotal (Total Children Is Unduplicated) 297 1026 1529.831740 $81082.5400 $53.0000
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Total 1338 6703.973335 $223386.0700 $33.3200
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Number of Children (Unduplicated) With at Least One Authorization 466