Summary Report for FSPSAs Ending During the Report Period Center: 51
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 341 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 5 5 5.790477 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 3.200000 $119.0400 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7 7 8.990477 $119.0400 $13.2400
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 1 1 0.750000 $37.5000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 23 23 26.000000 $1336.6600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $257.0500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 12 12.000000 $616.9200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 10.857143 $558.1600 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 6.000000 $308.4600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $154.2300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 54 57 68.607143 $3526.0300 $51.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.250000 $6.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.866667 $43.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.866667 $143.3400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 23.433334 $1171.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 61 64 425.495240 $21274.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 13.823810 $691.1900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 82 88 660.252386 $47511.7600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 34.142858 $2456.9200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 16 16 120.357143 $8660.9000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 90 639.428573 $46013.2500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 3.590476 $258.3700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 12.857143 $925.2000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 11.428571 $159.5400 $13.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 200 277 1949.792868 $134316.4800 $68.8900
-------------------------------------------------------------------------------------------------------------------------------------
Total 341 2027.390488 $137961.5600 $68.0500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 247