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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 215 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.677778 $25.2100 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 0.352381 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.030159 $25.2100 $24.4800
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 12 12 16.000000 $822.5600 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 5.000000 $257.0500 $51.4100
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Subtotal (Total Children Is Unduplicated) 24 26 30.000000 $1542.3000 $51.4100
EI Services, Class # 03
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 8.285714 $414.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 63 64 398.352386 $19917.6100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 29.714286 $1485.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 44 322.857141 $23232.8200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 7.090476 $510.2300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 4 39.714287 $2287.5400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 7 8 47.857145 $3443.8000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 9.928572 $714.4500 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 9.142857 $657.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 48 384.285716 $27653.2100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 39.000000 $2806.4500 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 5.714286 $411.2000 $71.9600
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Subtotal (Total Children Is Unduplicated) 149 186 1301.942866 $83535.2300 $64.1600
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Total 215 1332.973025 $85102.7400 $63.8400
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Number of Children (Unduplicated) With at Least One Authorization 164