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: 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 389 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 0.600000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 6.498412 $241.7400 $37.2000
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Subtotal (Total Children Is Unduplicated) 4 4 7.098412 $241.7400 $34.0600
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 23 25 25.000000 $1452.7500 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 27.142858 $1577.2700 $58.1100
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Subtotal (Total Children Is Unduplicated) 42 47 61.142858 $3553.0100 $58.1100
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 6.928571 $346.4300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.500000 $125.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.885714 $147.1400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 4.000000 $200.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 105 108 744.485734 $40202.2100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 12.142857 $655.7200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 54 415.457144 $33785.0000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 19.714286 $1603.1700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 9 9 120.428572 $7842.3200 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.857143 $641.8900 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.142857 $11.6200 $81.3400
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 1.000000 $65.1200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 36 36 246.804764 $20070.1500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 5.528571 $449.5900 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 108 874.776204 $71136.8000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 47.571429 $3868.5100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 4.142857 $336.9000 $81.3200
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Subtotal (Total Children Is Unduplicated) 262 338 2521.366703 $181487.5800 $71.9800
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Total 389 2589.607973 $185282.3200 $71.5500
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Number of Children (Unduplicated) With at Least One Authorization 282