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 482 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 1 1 1.466667 $54.5600 $37.2000
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Subtotal (Total Children Is Unduplicated) 13 14 42.142856 $54.5600 $1.2900
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 1 1 20.571429 $1057.5800 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 38 39 63.428571 $3260.8700 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 9.000000 $462.6900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 22.142857 $1138.3700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 6 6.000000 $308.4600 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 8 8.000000 $411.2800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $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 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 16.428571 $844.5900 $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 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) 83 90 162.321428 $8336.8500 $51.3600
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 14 16 341.290474 $17064.5400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 35 51 820.852380 $41042.6400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 6 98.428572 $4921.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 104 1751.933332 $126069.1300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 56.142857 $4040.0400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 6 7 60.999999 $3513.6000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 26 39 593.747617 $42726.0600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 25.428571 $1829.8400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 102 132 2530.223805 $182074.9300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 48.428571 $3484.9200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 3 36.142858 $2600.8400 $71.9600
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Subtotal (Total Children Is Unduplicated) 193 378 6418.361893 $436826.3600 $68.0600
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Total 482 6622.826177 $445217.7700 $67.2200
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Number of Children (Unduplicated) With at Least One Authorization 228