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 1303 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 78 78 4348.633332 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 12 12 2785.788889 $103631.3500 $37.2000
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Subtotal (Total Children Is Unduplicated) 90 90 7134.422221 $103631.3500 $14.5300
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 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 2.109590 $158.2200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $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 39 39 78.000000 $5850.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $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 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 45 45 90.000000 $4995.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 21 21 42.000000 $2331.0000 $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 7 8 1.427779 $73.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.327778 $16.8500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 7 2.400001 $123.3900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 21 21 16.179378 $831.7900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 1.966667 $101.1100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.111111 $5.7100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.138889 $58.5500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 11 7.627778 $392.1500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.411111 $123.9500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 26 27 9.894443 $508.6700 $51.4100
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Subtotal (Total Children Is Unduplicated) 174 251 356.216748 $22896.3200 $64.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.238889 $31194.5000 $5000.0100
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 148 161 93.726988 $4686.3700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 61 63 71.355554 $1783.8900 $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 96 98 60.250794 $3012.5500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.144444 $7.2200 $49.9800
CONSP -CONSP CONSULT, SLP, PHONE 57 59 63.261110 $1581.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 56 59 404.423810 $20221.2000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 5.857143 $292.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 25 103.027780 $7413.8500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 16 17 136.857143 $7882.9600 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 2.714286 $156.3400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 16 17 128.119049 $9219.4400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 9 44.035715 $2534.6900 $57.5600
SENS -V5264 EARMOLD 1 1 0.133333 $2.4200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 34 201.928573 $14530.7900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 10.428571 $750.4400 $71.9600
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Subtotal (Total Children Is Unduplicated) 292 962 1623.164303 $116946.3500 $72.0500
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Total 1303 9113.803272 $243474.0200 $26.7100
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Number of Children (Unduplicated) With at Least One Authorization 486