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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 11343 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 222 238 16165.376186 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 181 202 130279.116665 $4846383.1300 $37.2000
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Subtotal (Total Children Is Unduplicated) 400 440 146444.492851 $4846383.1300 $33.0900
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 3.833333 $215.0500 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 4.600000 $89.7500 $19.5100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 4.111111 $186.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.044444 $352.5700 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 114 151 235.187595 $11759.3900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 26 30 43.129831 $2156.5000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 41 41 72.033333 $3601.6700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 10 19.666667 $1475.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 72 74 142.027701 $10652.0800 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $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 37 37 74.000000 $5550.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 26 26 48.022222 $2665.2300 $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 1104 1116 2220.133334 $166510.0100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 260 262 521.000000 $39075.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 201 201 398.066667 $29855.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 58 58 116.000000 $8700.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 301 301 601.000000 $45075.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 67 67 131.000000 $9825.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 649 659 1316.066667 $73041.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 143 144 288.000000 $15984.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 188 270 172.654055 $8876.2000 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.138889 $58.5500 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 12 13 12.638888 $649.7600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 39 45 32.389685 $1665.1700 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 221 256 281.069074 $14449.7800 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 18 20 17.416666 $895.3900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 7 7 9.000000 $462.6900 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 5 5 6.955556 $357.5900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 104 153 114.283344 $5875.3600 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 6 8 5.944445 $305.6100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 29.730953 $1528.4700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 12 22 38.828572 $1996.1800 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 82 98 85.488891 $4394.9900 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 9 10 11.055556 $568.3700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 37 31.516669 $1620.2800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 3 2.405556 $123.6700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 372 496 398.855572 $20505.2500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 6 2.650000 $136.2400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 7 10 6.155556 $316.4600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.427778 $21.9900 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.272222 $13.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 1939 4684 7556.806311 $495465.3500 $65.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 18 17.594444 $87972.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 6.588889 $329.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 9 11 24.333333 $5636.0800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 78 107 73.958345 $3697.9800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 8 8.000000 $400.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 10 19.530556 $488.2700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 498 732 1070.779370 $53539.0000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 8 8 6.311112 $315.5600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 261 359 1119.267470 $27981.7100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 310 755 885.319819 $44265.8800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 8 9.088888 $454.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 119 289 722.650007 $18066.2700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 95 282 359.738887 $17986.9400 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.588889 $29.4500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 44 134 371.161118 $9279.0500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 429 599 918.156352 $45907.8300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 6 6 4.322223 $216.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 254 343 1016.605567 $25415.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 76.285715 $3814.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 519 777 12486.280921 $624314.1900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 37 49 586.142855 $29307.1600 $50.0000
INTR -T1013 INTERPRETER 2 2 4.500000 $225.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 237 343 5340.392839 $384294.8000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 5 54.428571 $3916.6800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 251 387 8211.957925 $473008.8000 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 109.571429 $6311.3100 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.344444 $24.7800 $71.9500
OCCT -97530TLHM OT SESSION BY OT ASST 2 3 136.571428 $7866.5200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 126 198 3183.070630 $229053.7800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 25.857143 $1860.6800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 96 169 3271.285712 $188295.2200 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 17.571429 $1011.4100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 24.571429 $1768.1600 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 2 14.000000 $805.8400 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 2 3 25.571429 $1471.8900 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 4.066666 $933.7300 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 2 3 8.644444 $1984.8400 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 5 6.400000 $2939.0100 $459.2200
SENS -V5264 EARMOLD 8 9 28.977778 $525.3700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 368 539 8075.801565 $581134.8700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 65.999998 $4749.3700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 16 25 403.914285 $29065.6700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 4 44.504762 $3202.5600 $71.9600
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Subtotal (Total Children Is Unduplicated) 1196 6219 48840.708666 $2923867.0700 $59.8700
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Total 11343 202842.007828 $8265715.5600 $40.7500
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Number of Children (Unduplicated) With at Least One Authorization 2081