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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 487 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 6 6 11.638096 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.377777 $51.2500 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 8 8 13.015873 $51.2500 $3.9400
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 35 35 38.285714 $2224.7800 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 8 8 8.000000 $464.8800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 16 16 21.571429 $1253.5100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 58 61 69.857143 $4059.4000 $58.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.755556 $37.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.966667 $148.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.833333 $70.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 21.285714 $1064.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 106 110 605.585713 $32701.6500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 28.428571 $1535.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 88 588.990480 $47896.6600 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 8 8 43.442856 $3532.7800 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 11 12 104.857140 $6828.3100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 40 40 188.728570 $15347.4300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.666667 $54.2200 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 0.714286 $58.0900 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 127 135 941.174600 $76536.3600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 28.852381 $2346.2900 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 305 418 2566.115867 $208299.8300 $81.1700
-------------------------------------------------------------------------------------------------------------------------------------
Total 487 2648.988883 $212410.4700 $80.1900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 350