Summary Report for FSPSAs Initiated During the Report Period Center: 05
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 1869 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 13 13 19.146031 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 19.146031 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 8.283333 $621.2500 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 2.033333 $152.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 7 7 4.041552 $303.1100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 20 29.334932 $1628.0900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 6.087671 $337.8700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 42 43 85.000000 $6375.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 81 82 122.744035 $9205.7700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 37 37 72.500000 $5437.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 4 4 7.000000 $525.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 19 19 34.500000 $2587.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 86 86 134.075540 $10055.6300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 72 73 139.642857 $7750.1800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 94 94 146.548860 $8133.4400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.002740 $150.2000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 1.305556 $66.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 32 33 27.484334 $1403.0800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 2.205555 $112.5900 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.127778 $6.5200 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 17 7.348022 $375.1200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 42 43 22.834398 $1165.6900 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 2.438889 $124.5100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 2.888888 $128.7000 $44.5500
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Subtotal (Total Children Is Unduplicated) 286 607 882.428273 $58056.3900 $65.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 3.117808 $15589.0000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 47 53 51.538890 $2576.9500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 16 19 12.527777 $626.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 4.733333 $118.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 248 258 327.510315 $16375.4900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 27 27 31.428572 $1571.4200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 130 133 170.189686 $8509.5000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 9 9 10.347619 $517.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.333333 $58.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 72 73 89.503972 $4475.2200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 10 10 13.055556 $652.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 195 199 236.986116 $11849.3300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 36 37 52.941269 $2647.0600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.788889 $19.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 244 253 1585.454749 $79272.8300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 14 78.300000 $3915.0000 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 51 334.726986 $23912.9000 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 8.571429 $612.3400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 8.571429 $612.3400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 37 37 220.533335 $15754.8800 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 2 2 11.609524 $829.3900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 8.571429 $612.3400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 48 50 326.527380 $23327.1200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.285714 $234.7300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 10.442857 $746.0400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 17.642857 $1260.4000 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 14.000000 $194.3200 $13.8800
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Subtotal (Total Children Is Unduplicated) 390 1249 3639.240824 $217071.5100 $59.6500
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Total 1869 4540.815128 $275127.9000 $60.5900
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Number of Children (Unduplicated) With at Least One Authorization 506