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: 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 1996 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 23 24 16.315875 $606.9600 $37.2000
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Subtotal (Total Children Is Unduplicated) 23 24 16.315875 $606.9600 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 10.000000 $453.2000 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 10 10 3.661109 $212.7400 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 22 14.872222 $864.2200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 1.677777 $97.4900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 10 10 15.862699 $921.7800 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 25 25 11.977777 $696.0200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.144444 $8.3900 $58.0900
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Subtotal (Total Children Is Unduplicated) 63 85 58.518250 $3272.5700 $55.9200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 8 1.561113 $78.0700 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 316 325 256.100017 $12805.0600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 31.260316 $1563.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 487 500 274.141287 $13707.1500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.233333 $11.6700 $49.9900
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 81 86 479.857145 $12956.1400 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 699 731 4833.596801 $261014.3100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 78 263.206349 $21403.9000 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 14.857143 $967.4900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 40 41 163.714286 $13313.2200 $81.3200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 79 272.071427 $22124.8300 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.071429 $460.4900 $65.1200
TRAV -TRAVS Travel by mile 10 10 58.857143 $26.1900 $0.4400
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Subtotal (Total Children Is Unduplicated) 781 1887 6657.527789 $360449.6600 $54.1400
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Total 1996 6732.361914 $364329.1800 $54.1200
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Number of Children (Unduplicated) With at Least One Authorization 811