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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1941 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 40 40 55.501586 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 40 55.501586 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 6 8.243835 $618.2900 $75.0000
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 13 13 20.010958 $1500.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $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 7 7 9.005479 $675.4100 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 14 22.200000 $1232.1000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 14 22.505479 $1249.0600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 34 35 68.500000 $5137.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 82 83 137.105174 $10282.8900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 9 9 14.500000 $1087.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 32 32 58.010958 $4350.8300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 24 24 45.500000 $3412.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 85 86 132.563010 $9942.2300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 91 91 176.066667 $9771.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 103 104 159.068489 $8828.3100 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 15 15 9.547716 $490.8500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.255556 $13.1400 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 6.972221 $358.4400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 1.866666 $95.9600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 3.111111 $159.9400 $51.4100
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 1 1 0.238356 $12.2600 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 8.772144 $450.9700 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 4 1.484931 $76.3400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 12 9.913546 $509.6500 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 5.000000 $257.0500 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.250000 $12.8500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 30 10.461489 $537.8200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.488889 $21.9300 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 17.428571 $922.4900 $52.9300
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Subtotal (Total Children Is Unduplicated) 312 651 980.571245 $64203.3800 $65.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 5.120548 $25602.5000 $4999.9500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 40 47.963492 $2398.1800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 20 21 27.413492 $1370.6800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 7.500000 $187.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 232 243 298.324608 $14916.2500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 68 69 84.110319 $4205.5200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.022222 $25.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 83 117.807146 $5890.3700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 41 42 52.707937 $2635.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.855556 $21.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 69 65.783334 $3289.1700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 32 34 39.261110 $1963.0500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 147 153 190.831743 $9541.5800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 63 63 90.375396 $4518.7700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.166667 $4.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 21 21 157.233331 $7861.6800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 246 256 1599.340484 $79966.9700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 31 33 172.714286 $8635.7000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 5.714286 $57.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 25 156.007143 $11226.2600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 3.857143 $277.5600 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.714286 $267.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 32 33 205.247619 $14769.6200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 27.357143 $1968.6200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 12.571429 $904.6400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 33.000001 $2374.6700 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 29 197.892857 $14240.3700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.033333 $1081.8000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 20.000000 $1439.2000 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 17.857143 $1285.0000 $71.9600
TRAV -TRAVS Travel by mile 1 1 45.000000 $20.0300 $0.4500
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Subtotal (Total Children Is Unduplicated) 357 1250 3701.784054 $222946.5800 $60.2300
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Total 1941 4737.856885 $287149.9600 $60.6100
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Number of Children (Unduplicated) With at Least One Authorization 507