Summary Report for FSPSAs Initiated During the Report Period Center: 05
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1687 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 18 18 26.512699 $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) 19 19 26.523810 $0.4100 $0.0200
Screening, Eval, and Assessment, Class # 02
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 7 12.500000 $937.5000 $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 2 2 2.022222 $151.6700 $75.0000
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 3 3 4.005479 $300.4100 $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 27.522222 $1527.4800 $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 53 53 102.500000 $7687.5000 $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 45 45 89.000000 $6675.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 61 61 119.500000 $8962.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 25 25 49.000000 $3675.0000 $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 80 81 158.000000 $8769.0000 $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 12 12 5.976484 $307.2500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.377778 $19.4200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 1.527548 $78.5200 $51.4000
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.077778 $4.0000 $51.4200
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 11 11 9.688889 $498.1100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.338889 $120.2400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 4 4 2.561111 $131.6700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 18 18 16.700000 $858.5500 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 2.866667 $147.3800 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 13.000000 $668.3300 $51.4100
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Subtotal (Total Children Is Unduplicated) 275 562 986.448172 $65562.2900 $66.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 82.000000 $410000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 40 36.816666 $1840.8300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 16 19 19.750000 $987.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 199 206 272.317351 $13615.8700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 57 57 74.239683 $3711.9800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 75 80 78.470236 $3923.5000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 48 50 60.755555 $3037.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.142857 $53.5700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 72 83.425399 $4171.2800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 30 30 29.611907 $1480.6000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 115 121 149.103174 $7455.1500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 52 53 69.011905 $3450.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 6.388888 $159.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 -3.833333 $-95.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 22.428571 $1121.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 223 1288.201605 $64410.0500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 32 32 152.442861 $7622.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 30 144.500002 $10398.2000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 8.255556 $594.0700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 34 36 199.885716 $14383.7600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.714286 $339.2400 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.714286 $627.0800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 32 168.623815 $12134.1500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 24.000001 $1727.0300 $71.9600
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Subtotal (Total Children Is Unduplicated) 301 1106 2982.966987 $567174.6700 $190.1400
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Total 1687 3995.938969 $632737.3700 $158.3500
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Number of Children (Unduplicated) With at Least One Authorization 445