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 1438 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 46 46 989.855555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 1151.733333 $42844.4800 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 51 51 2141.588888 $42844.4800 $20.0100
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 16 18 28.505556 $1425.2800 $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 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 38 38 75.000000 $5625.0000 $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 17 17 34.000000 $2550.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 58 58 116.000000 $6438.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 28.000000 $1554.0000 $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 6 6 1.766667 $90.8300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.383333 $19.7100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 3.700000 $190.2200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.366667 $18.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 1.594444 $81.9700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.1400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 1.261111 $64.8300 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 18 5.236510 $269.2200 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 163 232 373.080878 $23635.1300 $63.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 1.655556 $8278.0000 $5000.1300
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.511111 $581.6200 $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 199 219 119.687300 $5984.3600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.450000 $22.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 105 109 121.666668 $3041.6700 $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 175 188 103.838890 $5191.9500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.222222 $11.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 101 104 117.527778 $2938.2000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 9.857143 $492.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 55 60 380.166664 $19008.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 20.714286 $1035.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 16 93.764286 $6747.2900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 17 17 165.714286 $9545.1400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 16 18 120.047617 $8638.6500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 6 40.000000 $2302.4000 $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 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 1 1 1.600000 $29.0100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 33 173.857143 $12510.7900 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 332 1155 1722.771425 $97567.1700 $56.6300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1438 4237.441191 $164046.7700 $38.7100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 449