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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3026 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 49 1407.855555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 54 54 7796.188889 $290018.2300 $37.2000
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Subtotal (Total Children Is Unduplicated) 103 103 9204.044444 $290018.2300 $31.5100
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.800000 $44.8800 $56.1000
EVAL -96111 DEVELOPMENTAL EVALUATION 19 23 36.677778 $1833.8900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 5 5.327701 $266.3900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 10.000000 $500.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 19 36.005479 $2700.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 337 337 668.066667 $50105.0000 $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 42 42 84.000000 $6300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 92 92 182.000000 $13650.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 12 12 22.000000 $1650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 209 209 416.066667 $23091.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 70.000000 $3885.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 58 60 15.677779 $806.0000 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.683333 $35.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.305556 $15.7100 $51.4200
OCTH -97166 OT EVAL MODERATE COMPLEXITY 12 12 5.499999 $282.7500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 68 68 61.630952 $3168.4400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 1.366667 $70.2600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 4.000000 $205.6400 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 2.450000 $125.9500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 31 34 7.633332 $392.4200 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.033333 $1.7100 $51.3600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 2.788889 $143.3800 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 27 21.183335 $1089.0400 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 1.022222 $52.5500 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 17 17 6.772222 $348.1600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 126 136 60.261910 $3098.1000 $51.4100
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Subtotal (Total Children Is Unduplicated) 650 1252 1910.259300 $127673.5800 $66.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 1.838889 $9194.5000 $5000.0300
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 4.788889 $1109.2100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 23 12.350003 $617.5200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 200 220 120.687300 $6034.3600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.450000 $22.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 106 110 122.666668 $3066.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 105 198 99.842853 $4992.1300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.177778 $8.8900 $50.0100
CONOP -CONOP CONSULT, OT, PHONE 29 59 72.200000 $1805.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 60 27.894444 $1394.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 23 22.800000 $570.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 176 189 104.838890 $5241.9500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.222222 $11.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 102 105 118.527778 $2963.2000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 9.857143 $492.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 208 225 1342.280938 $67114.1100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 15 98.571429 $4928.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 87 92 555.107144 $39945.5100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 23.142857 $1665.3600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 88 92 800.928568 $46133.5000 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 15.428571 $888.6900 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.094444 $6.7900 $71.9300
PHY -97110 PT SESSION BY LICENSED PT 43 46 296.984123 $21370.9800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 32 36 275.285713 $15845.4500 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 5.714286 $328.9200 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.511111 $346.9600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.000000 $1377.6600 $459.2200
SENS -V5264 EARMOLD 3 3 3.877778 $70.3000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 126 141 829.735709 $59707.8500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 20.142857 $1449.4800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 12.452381 $896.0700 $71.9600
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Subtotal (Total Children Is Unduplicated) 485 1671 5008.400766 $299825.8100 $59.8600
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Total 3026 16122.704510 $717517.6100 $44.5000
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Number of Children (Unduplicated) With at Least One Authorization 801