Summary Report for FSPSAs Ending During the Report Period Center: 55
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 2720 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 82 82 4413.444443 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 61 62 12881.800000 $479202.9600 $37.2000
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Subtotal (Total Children Is Unduplicated) 143 144 17295.244443 $479202.9600 $27.7100
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.622223 $31.1200 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 11 14 27.000000 $2025.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 32 34 64.788889 $4859.1700 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 2.109590 $158.2200 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 33.322223 $1849.3900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 279 283 564.000000 $42300.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 41 41 81.000000 $6075.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 52 52 104.000000 $7800.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 67 67 134.000000 $10050.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 11 11 21.000000 $1575.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 153 153 304.000000 $16872.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 44 44 88.000000 $4884.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
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 65 68 19.418648 $998.3300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 1.327778 $68.2600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 16 6.305557 $324.1800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 76 80 78.865886 $4054.5000 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 2.755555 $141.6600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 39 39 11.338893 $582.9500 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.238889 $12.2800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.111111 $5.7100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 4.877778 $250.7700 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 20 11.562710 $594.4400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.350000 $17.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 5.244444 $269.6100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.122222 $6.2800 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 125 132 51.991628 $2672.8800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.077778 $4.0000 $51.4200
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.411111 $123.9500 $51.4100
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Subtotal (Total Children Is Unduplicated) 671 1151 1689.848392 $113623.7500 $67.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 6.477778 $32389.0000 $5000.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 25 26 22.622222 $1131.1100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 2 2.000000 $100.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 149 162 94.582544 $4729.1500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 62 64 73.922221 $1848.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 123 205 120.305564 $6015.3200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 2 1.977778 $98.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 80 84.299998 $2107.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 64 29.444449 $1472.2500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 15 29 30.011110 $750.2800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 99 61.106350 $3055.3300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.144444 $7.2200 $49.9800
CONSP -CONSP CONSULT, SLP, PHONE 58 60 65.827777 $1645.6900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 162 175 1134.085717 $56704.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 9 9 36.833334 $1841.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 93 105 586.170639 $42180.8000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.857143 $61.6800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 76 82 736.000004 $42393.5900 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 2.714286 $156.3400 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 1.428571 $82.2900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 53 55 368.538099 $26519.9800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 40 43 296.121430 $17044.7500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 7.285714 $419.3600 $57.5600
SENS -V5264 EARMOLD 1 1 0.133333 $2.4200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 125 138 890.770641 $64099.8200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 18.285714 $1315.8400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 6 7 42.285715 $3042.8900 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.133333 $369.3900 $71.9600
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Subtotal (Total Children Is Unduplicated) 437 1425 4719.365908 $311584.8600 $66.0200
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Total 2720 23704.458743 $904411.5700 $38.1500
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Number of Children (Unduplicated) With at Least One Authorization 917