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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 331 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 1 1 0.700000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.700000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 29 29 -19.571429 $-1006.1700 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $257.0500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
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Subtotal (Total Children Is Unduplicated) 43 44 -4.571429 $-236.4300 $51.7200
EI Services, Class # 03
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.233333 $5.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 33.142857 $1657.1400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 50 51 312.785717 $15639.2800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 43.000000 $2150.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 61 62 362.000002 $26049.5200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 7.857143 $565.4000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 11 11 138.999999 $8006.4100 $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 20 21 49.571433 $3567.1600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 16.500000 $1187.3400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 114 118 702.476196 $50550.1500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 34.714286 $2498.0400 $71.9600
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Subtotal (Total Children Is Unduplicated) 213 286 1710.566680 $112378.5300 $65.7000
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Total 331 1706.695251 $112142.1100 $65.7100
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Number of Children (Unduplicated) With at Least One Authorization 225