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 1331 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 48 49 2964.455557 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 672.000000 $24998.4000 $37.2000
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Subtotal (Total Children Is Unduplicated) 51 52 3636.455557 $24998.4000 $6.8700
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 26 34 44.938814 $2246.9400 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 8 12.219178 $610.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 12 12 22.000000 $1100.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 27 27 54.000000 $4050.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $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 10 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 23 23 46.000000 $2553.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 1.155556 $59.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.233333 $11.9900 $51.4000
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 3.844445 $197.6500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.411111 $21.1300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 3.011112 $154.8100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.077778 $4.0000 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.005556 $103.1100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.477778 $24.5600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 4.299999 $221.0600 $51.4100
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Subtotal (Total Children Is Unduplicated) 135 185 272.674660 $16935.6200 $62.1100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.555556 $27.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.066667 $15.4500 $231.7400
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 59 62 435.142858 $21757.1400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.142857 $207.1500 $50.0000
INTR -T1013 INTERPRETER 1 1 2.500000 $125.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 63.952382 $4602.0100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 14 15 108.000001 $6220.8000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 7 7 38.714285 $2785.8800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 3 18.571429 $1068.9700 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 1.428571 $82.2300 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.066667 $15.3200 $229.7200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.116667 $53.5900 $459.3500
SENS -V5264 EARMOLD 1 1 0.133333 $2.4200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 99.571430 $7165.1600 $71.9600
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Subtotal (Total Children Is Unduplicated) 309 1094 1464.634912 $70551.9000 $48.1700
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Total 1331 5373.765129 $112485.9200 $20.9300
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Number of Children (Unduplicated) With at Least One Authorization 430