Summary Report for FSPSAs Ending During the Report Period Center: 57
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1541 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
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 4.233335 $157.4900 $37.2000
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Subtotal (Total Children Is Unduplicated) 9 9 4.233335 $157.4900 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 3.000000 $135.9600 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.683334 $39.7100 $58.1200
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.211111 $12.2700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 1.833333 $106.5300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 3.683334 $214.0400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 3.616668 $210.1700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.022222 $1.2900 $58.0500
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Subtotal (Total Children Is Unduplicated) 30 33 15.050002 $836.2000 $55.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.277778 $13.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 374 422 265.673016 $13283.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 44 39.409526 $1970.4900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 543 594 339.822221 $16991.1200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 19 21 111.214280 $3002.8000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 301 325 2334.411102 $126058.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 24 73.857147 $6006.0800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 18 18 86.071432 $6999.3400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 7.857143 $511.6600 $65.1200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 31 132.357146 $10763.3200 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.642857 $172.1100 $65.1200
TRAV -TRAVS Travel by mile 13 14 96.009525 $42.7200 $0.4500
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Subtotal (Total Children Is Unduplicated) 734 1499 3491.603173 $190833.6100 $54.6600
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Total 1541 3510.886510 $191827.2900 $54.6400
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Number of Children (Unduplicated) With at Least One Authorization 744