Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1936 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 1 1 0.633333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.633333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 13.890868 $673.7100 $48.5000
EXIT -EXIT EXIT ASSESSMENT 22 22 25.002740 $1250.1400 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $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 11 11 17.510958 $1313.3300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 10 11 21.000000 $1575.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 36 36 63.016437 $3497.4200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 29.500000 $1637.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 19.500000 $1462.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 2.533333 $126.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.366667 $18.8500 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 4.222222 $217.0600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.202740 $113.2400 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.186301 $9.5800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.088889 $4.5700 $51.4200
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.366667 $18.8500 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.483333 $127.6700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 2.000000 $102.8200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.186301 $9.5800 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 3.866438 $198.7700 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.323288 $16.6200 $51.4000
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.186301 $9.5800 $51.4100
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Subtotal (Total Children Is Unduplicated) 111 166 233.433483 $14156.6000 $60.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 2.149999 $10749.5000 $4999.7700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 34 42.649710 $2132.4900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 3.505556 $175.2800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 193 204 347.176188 $17358.8000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 94 95 163.038095 $8151.9000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 3.300000 $165.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 29.116665 $1455.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 178 181 301.071427 $15053.5600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.666667 $133.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.533333 $63.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 12 12 69.371429 $3468.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 36 37 250.519050 $12525.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 42.142857 $2107.1500 $50.0000
INTR -T1013 INTERPRETER 20 32 77.469765 $3873.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 238 493 2105.462624 $21054.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 60.999999 $4389.5700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 8 9 97.142858 $6990.4000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 58.000000 $4173.6900 $71.9600
TRAV -TRAVS Travel by mile 267 613 116077.435295 $51654.4600 $0.4500
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Subtotal (Total Children Is Unduplicated) 293 1769 119740.184850 $165853.5800 $1.3900
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Total 1936 119974.251666 $180010.1800 $1.5000
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Number of Children (Unduplicated) With at Least One Authorization 320