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: 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 1420 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 15 15 10.077778 $374.8900 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 15 15 10.077778 $374.8900 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.000000 $362.5600 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 13 13 5.705557 $331.5600 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 10.477778 $608.8700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.938889 $54.5600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 3.955555 $229.8500 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 9 10 5.555555 $322.8300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.355556 $20.6600 $58.1200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 42 56 37.988890 $2105.2200 $55.4200
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 226 234 200.920630 $10045.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 25.690475 $1284.5200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 359 371 285.642849 $14282.0900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.766667 $38.3400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 49 52 406.714292 $10981.3000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 526 548 4942.863541 $266914.6300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 52 242.042861 $19682.8600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.857143 $511.6500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 23 23 102.500002 $8335.2700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 40 160.928574 $13086.6600 $81.3200
TRAV -TRAVS Travel by mile 14 14 122.219049 $54.3900 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 566 1349 6498.146083 $345217.6800 $53.1300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1420 6546.212751 $347697.8000 $53.1100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 580