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
Eligibility Filter: Program Patients
With the filters selected there were 140 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
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 9.000000 $462.6900 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 2 2.000000 $102.8200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 6 7.447619 $382.8800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 17 22 23.447619 $1204.0300 $51.3500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 2.433333 $121.6700 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 25.428571 $1271.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 9 10 74.500000 $3725.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 26.571429 $1328.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 26 158.857142 $11431.3600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 9.714285 $699.0400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.142857 $238.6300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.142857 $238.6300 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 4.142857 $238.6300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 12 13 66.219048 $4765.1100 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 47 49 280.142858 $20159.0800 $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) 79 115 665.009523 $44753.3500 $67.3000
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Total 140 689.487301 $45982.6000 $66.6900
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Number of Children (Unduplicated) With at Least One Authorization 91