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: 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 2627 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 49 50 3084.455557 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 53 53 11919.415874 $443402.2700 $37.2000
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Subtotal (Total Children Is Unduplicated) 101 103 15003.871431 $443402.2700 $29.5500
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 32 41 51.961036 $2598.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 8 9 14.219178 $710.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 14 14 24.644444 $1232.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 19 19 38.000000 $2850.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 168 172 344.000000 $25800.0000 $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 33 33 66.000000 $4950.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 39 40 80.000000 $6000.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 18 18 36.000000 $2700.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 89 90 180.000000 $9990.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 31 32 64.000000 $3552.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 64 65 20.158730 $1036.3600 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.216667 $11.1400 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 3.083333 $158.5100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 2.027776 $104.2400 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 54 55 35.480517 $1824.0500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 2.072223 $106.5400 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $154.2300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 36 37 17.335715 $891.2300 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.238889 $12.2800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.555556 $28.5600 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 25 26 13.938890 $716.6000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 3.311111 $170.2200 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.022222 $1.1400 $51.3600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 117 120 44.353168 $2280.1600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.1400 $51.4200
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.338889 $17.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.177778 $7.9800 $44.8700
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Subtotal (Total Children Is Unduplicated) 536 898 1221.313900 $80792.8600 $66.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 3.261111 $16305.5000 $4999.9800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.555556 $27.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.066667 $247.0700 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 27 19.488890 $974.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 6.016667 $150.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 175 191 110.244446 $5512.2300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 0.200000 $10.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 96 106 112.138886 $2803.4700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 96 173 85.383333 $4269.1700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 2 0.400000 $20.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 48 89 80.949997 $2023.7400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 76 33.588883 $1679.4200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 18 35 25.272221 $631.8000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 156 165 104.492063 $5224.6000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.166667 $8.3400 $50.0100
CONSP -CONSP CONSULT, SLP, PHONE 94 100 102.044442 $2551.1100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.285714 $564.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 196 213 1435.642860 $71782.1400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 31.000000 $1550.0000 $50.0000
INTR -T1013 INTERPRETER 1 1 2.500000 $125.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 74 378.268259 $27220.1600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 11.285714 $812.1300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 95 102 849.571429 $48935.3500 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 16.285714 $938.0600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 44 46 283.757143 $20419.1500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 10.142857 $729.8800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 42 44 292.503176 $16836.4900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.142857 $296.0300 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 1.428571 $82.2300 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 3.142857 $180.9100 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.066667 $15.3200 $229.7200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 0.861112 $395.4800 $459.2700
SENS -V5264 EARMOLD 3 3 1.133333 $20.5500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 128 133 940.671432 $67690.7300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 26.857143 $1932.6400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 6 6 25.428572 $1829.8400 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.466667 $393.3800 $71.9600
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Subtotal (Total Children Is Unduplicated) 453 1626 5017.711906 $305188.8100 $60.8200
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Total 2627 21242.897237 $829383.9500 $39.0400
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Number of Children (Unduplicated) With at Least One Authorization 766