Summary Report for FSPSAs Ending During the Report Period Center: 05
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1921 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 21 21 30.787300 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.011111 $0.4100 $37.1600
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Subtotal (Total Children Is Unduplicated) 22 22 30.798411 $0.4100 $0.0100
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 8 11.220700 $841.5500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $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 1 1 0.022222 $1.6700 $74.9300
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 10.000000 $750.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 18 27.366666 $1518.8500 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 11 11 18.505479 $1027.0600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 73 74 143.005479 $10725.4100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 54 54 104.500000 $7837.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 11.500000 $862.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 46 46 91.000000 $6825.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 60 60 117.500000 $8812.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 26 26 51.000000 $3825.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 80 80 156.005479 $8658.3100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 78 79 154.000000 $8547.0000 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.261112 $13.4300 $51.4300
OCTH -97165 OT EVAL LOW COMPLEXITY 14 14 7.100989 $365.0600 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 2.722223 $139.9500 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.461111 $23.7100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 1.944444 $99.9600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 2 2.000000 $102.8200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 0.810655 $41.6800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 13 13 12.461111 $640.6300 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.377778 $19.4200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.066667 $3.4300 $51.4300
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 0.927778 $47.7000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 1.183333 $60.8300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 6.580213 $338.2900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.063014 $3.2400 $51.4000
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.938888 $48.2600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 16 10.016667 $514.9600 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 2.727778 $140.2400 $51.4100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 11.857143 $609.5700 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 4 22.000000 $1131.0200 $51.4100
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Subtotal (Total Children Is Unduplicated) 325 584 1012.532408 $66950.4600 $66.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 5.000000 $25000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 40 38.161111 $1908.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 17 21 20.850000 $1042.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 238 250 309.757931 $15487.8700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 65 68 85.915079 $4295.7400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 105 101.950001 $5097.5100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 69 72 85.446822 $4272.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 73 65.713889 $3285.7000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 30 30 27.280555 $1364.0300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 120 148.393249 $7419.6300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 62 65 71.705950 $3585.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.377778 $9.4500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 10.066667 $251.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 14 14 70.500001 $3525.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 244 261 1366.803179 $68340.1800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 52 55 262.592066 $13129.6000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 41 233.406350 $16795.9500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 25.112699 $1807.1200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 36 37 199.576190 $14361.5000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 9.214285 $663.0600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 3.857143 $277.5600 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 38 176.404765 $12694.0900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 3.071429 $221.0200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 3.000000 $215.8800 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $442.0400 $71.9600
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Subtotal (Total Children Is Unduplicated) 361 1315 3331.299996 $205517.6800 $61.6900
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Total 1921 4374.630815 $272468.5600 $62.2800
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Number of Children (Unduplicated) With at Least One Authorization 605