Summary Report for FSPSAs Ending During the Report Period Center: 52
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 607 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 5 5 5.055556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 5.055556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.000000 $174.3300 $58.1100
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Subtotal (Total Children Is Unduplicated) 6 6 8.000000 $464.8800 $58.1100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 203 236 566.785713 $28339.2800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 4.733333 $236.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 125 131 346.833336 $17341.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 77 91 242.400002 $12120.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 103 104 247.166668 $12358.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.200000 $180.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 21 116.733333 $6303.6000 $54.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 3.638096 $295.8500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.333333 $189.7400 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 14.128571 $1148.9400 $81.3200
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Subtotal (Total Children Is Unduplicated) 255 596 1551.952385 $78514.1100 $50.5900
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Total 607 1565.007941 $78978.9900 $50.4700
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Number of Children (Unduplicated) With at Least One Authorization 263