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 1194 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 48 2014.742856 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 12 12 3060.000000 $113832.0000 $37.2000
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Subtotal (Total Children Is Unduplicated) 60 60 5074.742856 $113832.0000 $22.4300
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 29 36 49.481355 $2474.0700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 6 12.000000 $600.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 9 9 17.000000 $850.0000 $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 28 29 58.000000 $4350.0000 $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 10 10 20.000000 $1500.0000 $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 25 25 50.000000 $2775.0000 $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 9 9 2.344444 $120.5300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 6.785615 $348.8400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 1.516667 $77.9700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 10.142857 $521.4500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 5 4.505556 $231.6300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.472223 $127.1000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 17 6.038096 $310.4200 $51.4100
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Subtotal (Total Children Is Unduplicated) 135 199 301.286813 $18565.4200 $61.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 1.811111 $9055.5000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.955556 $221.3400 $231.6300
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 47 49 322.857138 $16142.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 19.285714 $964.2900 $50.0000
INTR -T1013 INTERPRETER 1 1 2.500000 $125.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 50.285714 $3618.5600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 12.285714 $884.0800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 7 8 82.285714 $4739.6600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 10 11 61.571427 $4430.6900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 5 32.571429 $1874.8100 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 5.142857 $296.0300 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.955556 $219.4200 $229.6200
SENS -V5264 EARMOLD 1 1 1.911111 $34.6500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 25 196.142857 $14114.4200 $71.9600
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Subtotal (Total Children Is Unduplicated) 279 935 1468.882926 $82685.2600 $56.2900
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Total 1194 6844.912595 $215082.6800 $31.4200
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Number of Children (Unduplicated) With at Least One Authorization 394