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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 219 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 3 3 2.422222 $90.1100 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1 1 2.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.355556 $13.2300 $37.2000
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Subtotal (Total Children Is Unduplicated) 5 5 4.777778 $103.3300 $21.6300
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 17 17 28.714286 $1668.5900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 20 20 31.714286 $1842.9200 $58.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 2.333333 $116.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.733333 $36.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.500000 $25.0000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 5.142857 $257.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 8.733333 $218.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 26 26 188.438093 $10175.6600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 10.428572 $563.1400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 47 48 265.490476 $21589.7000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 0.285714 $23.2300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 3 3 24.857142 $1618.6900 $65.1200
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 9.000000 $586.0800 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 21 21 94.597619 $7692.6800 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 76 413.571426 $33631.6600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 24.142857 $1963.3000 $81.3200
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Subtotal (Total Children Is Unduplicated) 129 194 1052.221422 $83597.1300 $79.4500
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Total 219 1088.713486 $85543.3800 $78.5700
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Number of Children (Unduplicated) With at Least One Authorization 149