Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 73 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 4 4 4.833333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 4.833333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
BEHV -H2014BA Behavior Analysis - Technician 1 1 12.857143 $626.9100 $48.7600
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 4.571429 $233.3700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
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Subtotal (Total Children Is Unduplicated) 8 9 22.428572 $1114.4800 $49.6900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.750000 $37.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 1.800000 $90.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.800000 $90.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 14 188.609523 $9430.4900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 85.714287 $6123.4300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 11.428571 $816.4600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 5.428571 $387.8200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 7 52.428573 $3745.4900 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 11.142857 $796.0500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 16 109.285712 $7807.3800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714285 $1265.5100 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 7.714285 $107.0700 $13.8800
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Subtotal (Total Children Is Unduplicated) 45 60 493.816664 $30697.2000 $62.1600
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Total 73 521.078569 $31811.6800 $61.0500
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Number of Children (Unduplicated) With at Least One Authorization 53