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: 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 2619 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 1426.755556 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 48 49 10178.333333 $378634.0000 $37.2000
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Subtotal (Total Children Is Unduplicated) 93 95 11605.088889 $378634.0000 $32.6300
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.405556 $12.3800 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.405556 $40.6500 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.405556 $5.6000 $13.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.355556 $17.7800 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 2 4.000000 $200.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 9 12 23.000000 $1725.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 36 64.722223 $4854.1700 $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 2 2 3.000000 $225.0000 $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 20 20 38.355556 $2128.7400 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 277 281 560.000000 $42000.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 40 40 80.000000 $6000.0000 $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 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 152 152 302.000000 $16761.0000 $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 55 58 20.900001 $1074.4700 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 -1.094444 $-56.2600 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.072222 $3.7100 $51.3900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 2.972223 $152.8100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 57 58 51.973822 $2671.9800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 25 26 6.249922 $321.3000 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 0.305555 $15.7100 $51.4000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.400000 $20.5600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 9 5.494444 $282.4700 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 20 20 15.307154 $786.9400 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.127778 $6.5700 $51.4200
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 12 6.572221 $337.8700 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 9.857143 $506.7500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 96 102 45.149246 $2321.1100 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.472222 $75.6900 $51.4100
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Subtotal (Total Children Is Unduplicated) 555 1066 1659.414991 $111752.6400 $67.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.311111 $6555.5000 $4999.9600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.544444 $126.0900 $231.6000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 28 28 22.854167 $1142.7100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 3.550000 $88.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 188 200 125.550003 $6277.5200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 0.922222 $46.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 94 99 107.000000 $2675.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 110 164 99.350004 $4967.5200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 34 61 83.038886 $2075.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 47 25.688887 $1284.4400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 16 22.600000 $565.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 147 152 82.400000 $4120.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 100 107 96.566664 $2414.1600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 222 1481.900015 $74094.9900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 25.428572 $1271.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 76 590.842856 $42517.0700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 12.285714 $884.0800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 54 55 525.285717 $30256.4300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 23.285714 $1341.2600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 4.857143 $349.5200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 41 43 283.767465 $20419.8900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 21.285715 $1531.7200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 29 37 276.283331 $15902.8800 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 2 1.088888 $250.0000 $229.5900
SENS -V5264 EARMOLD 3 3 3.266666 $59.2200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 114 782.395240 $56301.1700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.285714 $524.2800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 6 6 65.142857 $4687.6800 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $71.9600 $71.9600
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Subtotal (Total Children Is Unduplicated) 451 1458 4778.777995 $282902.3200 $59.2000
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Total 2619 18043.281875 $773288.9500 $42.8600
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Number of Children (Unduplicated) With at Least One Authorization 715