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 5417 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 213 229 15630.109519 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 30 34 23038.322222 $857025.5900 $37.2000
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Subtotal (Total Children Is Unduplicated) 243 263 38668.431741 $857025.5900 $22.1600
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 1 1 1.000000 $115.8100 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 104 136 211.826484 $10591.3300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 22 26 37.124352 $1856.2200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 38 38 68.388889 $3419.4500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 5.666667 $425.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 22.000000 $1650.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 129 130 260.000000 $19500.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 24 25 49.000000 $3675.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 38 75.000000 $5625.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 48 48 96.000000 $7200.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 193 194 388.000000 $21534.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 42 42 84.000000 $4662.0000 $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 26 31 18.016669 $926.2500 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.444444 $22.8500 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 8 3.844444 $197.6400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 33 37 34.857156 $1792.0100 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 3.794444 $195.0700 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 18 25 11.455557 $588.9400 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.011111 $51.9800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 24.714286 $1270.5600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 2 1.116667 $57.4100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 19 12.405555 $637.7700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 8 9 10.650000 $547.5200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 51 66 55.390480 $2847.6500 $51.4100
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Subtotal (Total Children Is Unduplicated) 579 931 1549.251649 $94314.9700 $60.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 12 12.494444 $62472.0000 $4999.9800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.455556 $22.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 5 11.666666 $2702.2200 $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 498 731 1070.612703 $53530.6600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 8 8 6.311112 $315.5600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 261 358 1118.767470 $27969.2100 $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 429 598 917.989685 $45899.5000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 6 6 4.322223 $216.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 254 342 1016.105567 $25402.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 6 76.285715 $3814.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 163 234 3727.719043 $186386.0100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 14 213.071426 $10653.5900 $50.0000
INTR -T1013 INTERPRETER 2 2 4.500000 $225.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 54 770.030950 $55411.4600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 42 57 1112.330157 $64070.2000 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 59.857143 $3447.7700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 37 57 800.652378 $57614.9600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 17 28 424.714287 $24446.5500 $57.5600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 2 14.000000 $805.8400 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 2 15.714286 $904.5200 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.022222 $464.3200 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 2 3 8.644444 $1984.8400 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 3 3 16.311111 $295.7200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 102 1473.776182 $106052.9800 $71.9600
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Subtotal (Total Children Is Unduplicated) 836 4223 15330.391279 $830695.4300 $54.1900
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Total 5417 55548.074669 $1782035.9800 $32.0800
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Number of Children (Unduplicated) With at Least One Authorization 1244