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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2239 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 27 15.120472 $733.3400 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.166667 $17.1300 $14.6800
EXIT -EXIT EXIT ASSESSMENT 19 19 18.569407 $928.4700 $50.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 18.016437 $1351.2400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 21 35.016437 $1943.4200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 6 10.000000 $750.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 9.000000 $675.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.364384 $70.1400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5700 $51.4200
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.8200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 0.255556 $13.1400 $51.4200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 81 120 148.676027 $9231.9100 $62.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 3.958219 $19791.0000 $4999.9800
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 48 50 59.449292 $2972.4800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 3.019445 $150.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 222 365.745236 $18287.2600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.366667 $68.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 124 126 195.249202 $9762.4500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.033333 $51.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 30.133334 $1506.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.500000 $62.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 194 200 322.910317 $16145.5200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 7.466667 $186.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 33.142857 $1657.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 43 43 257.452379 $12872.6300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 21.000000 $1050.0000 $50.0000
INTR -T1013 INTERPRETER 11 20 44.057988 $2202.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 254 586 2210.089585 $26521.0900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 23.285713 $1675.6500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 5 5 10.142856 $729.8800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 19.428572 $1398.0800 $71.9600
TRAV -TRAVS Travel by mile 312 801 129568.675889 $57658.0600 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 327 2119 133185.824218 $174938.2200 $1.3100
-------------------------------------------------------------------------------------------------------------------------------------
Total 2239 133334.500245 $184170.1300 $1.3800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 340