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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1403 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 12 13 40.676189 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 3.200000 $119.0400 $37.2000
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Subtotal (Total Children Is Unduplicated) 14 15 43.876189 $119.0400 $2.7100
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 7 7 5.750000 $287.5000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 21.571429 $1108.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 113 117 197.714284 $10164.5000 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 30 30 50.142857 $2577.8500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 5 5 25.142857 $1292.6000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 23 23.000000 $1182.4300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 13 14 34.142857 $1755.2900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 5.000000 $257.0500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 16.857143 $866.6200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 21 21 30.428571 $1564.3300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 15 15.000000 $771.1500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 229 254 435.749998 $22393.8200 $51.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 26.892857 $1344.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.250000 $6.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 16.733333 $836.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.966667 $74.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.966666 $48.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.966667 $74.1700 $25.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.966667 $74.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 17 19 380.576188 $19028.8300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 253 4497.580943 $224879.1600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 22 27 488.714285 $24435.7300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 237 322 5850.419038 $420996.2200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 13 16 332.690476 $23940.4100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 14 16 124.428571 $7167.0900 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 20.142857 $1449.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 61 94 1461.680951 $105182.5400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 63.142857 $4543.7600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 52.000000 $3741.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 258 341 7032.990466 $506094.0500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 18 24 380.066665 $27349.6100 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 4 60.714287 $4368.9900 $71.9600
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Subtotal (Total Children Is Unduplicated) 619 1134 20799.890441 $1380636.1800 $66.3800
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Total 1403 21279.516628 $1403149.0300 $65.9400
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Number of Children (Unduplicated) With at Least One Authorization 688