Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2366 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 50 50 2135.487300 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 38 38 12159.000000 $452314.8000 $37.2000
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Subtotal (Total Children Is Unduplicated) 88 88 14294.487300 $452314.8000 $31.6400
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 33 41 54.936911 $2746.8500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 6 12.000000 $600.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 10 10 17.644444 $882.2200 $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 171 176 352.000000 $26400.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 57 57 114.000000 $8550.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 34 34 68.000000 $5100.0000 $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 92 93 186.000000 $10323.0000 $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 65 67 22.333331 $1148.1400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 4.683333 $240.7700 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 51 52 42.576884 $2188.8700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.8200 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 4.000000 $205.6400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 40 42 22.549207 $1159.2500 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 4 1.227778 $63.1200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 10.542857 $542.0100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 1.072222 $55.1200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 18 12.755557 $655.7700 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 0.500000 $25.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 4.188890 $215.3600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 112 123 31.876983 $1638.7900 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.1400 $51.4200
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Subtotal (Total Children Is Unduplicated) 494 895 1247.066175 $82434.3900 $66.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 6 3.811111 $19055.5000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.488889 $344.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 28 19.055557 $952.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.900000 $72.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 148 157 108.277778 $5413.8900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.033333 $1.6700 $49.9500
CONIP -CONIP CONSULT, ITDS PHONE 77 80 94.683333 $2367.0800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 82 151 83.398808 $4169.9300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 4 3.288888 $164.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 76 84.455551 $2111.3800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 69 31.400003 $1570.0200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 43 48.094441 $1202.3500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 132 98.497619 $4924.8800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 70 70 87.950003 $2198.7600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.285714 $814.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 176 1300.428559 $65021.4600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 27.804761 $1390.2400 $50.0000
INTR -T1013 INTERPRETER 1 1 2.500000 $125.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 69 463.309520 $33339.7600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 18.285714 $1315.8400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 81 89 781.685712 $45025.1200 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 19.285714 $1110.8600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 42 43 282.285712 $20313.2900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.000000 $359.8000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 41 43 379.428572 $21839.9000 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 8.000000 $460.4800 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.428571 $390.6400 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 2 2 7.428571 $427.5900 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 10.000000 $575.6000 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.955556 $219.4200 $229.6200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 2 2 2.444444 $44.3200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 113 116 785.385710 $56516.3500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 14.000000 $1007.4400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 25.142857 $1809.2800 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.666667 $47.9800 $71.9600
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Subtotal (Total Children Is Unduplicated) 414 1383 4824.087668 $297163.8800 $61.6000
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Total 2366 20365.641143 $831913.0800 $40.8500
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Number of Children (Unduplicated) With at Least One Authorization 655