Summary Report for FSPSAs Initiated During the Report Period Center: 57
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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2079 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 25 25 10.577778 $393.4900 $37.2000
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Subtotal (Total Children Is Unduplicated) 25 25 10.577778 $393.4900 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 11.000000 $498.5200 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 16 16 5.272223 $306.3700 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 30 30 23.922223 $1390.1300 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 12 14 3.194443 $185.6200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 8.111112 $471.3400 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 34 35 20.288889 $1178.9900 $58.1100
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Subtotal (Total Children Is Unduplicated) 78 120 74.788890 $4205.3000 $56.2300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 0.711112 $35.5600 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 314 325 302.988093 $15149.3700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 28 50.935715 $2546.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 507 520 318.751574 $15937.5200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 77 83 578.499996 $15619.5100 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 704 746 5682.590474 $306859.8700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 80 83 376.428573 $30611.1900 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 13.428572 $874.4600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 47 49 189.142860 $15381.1000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 10.000000 $651.2000 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 76 276.071432 $22450.1400 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 19.142857 $1246.5900 $65.1200
TRAV -TRAVS Travel by mile 14 17 98.290477 $43.7400 $0.4500
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Subtotal (Total Children Is Unduplicated) 776 1934 7916.981735 $427407.0300 $53.9900
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Total 2079 8002.348403 $432005.8200 $53.9800
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Number of Children (Unduplicated) With at Least One Authorization 795