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 873 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 6 6 4.544444 $169.0500 $37.2000
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Subtotal (Total Children Is Unduplicated) 6 6 4.544444 $169.0500 $37.2000
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.411111 $82.0000 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 3.277778 $190.4700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.938889 $54.5600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.688889 $156.2500 $58.1100
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Subtotal (Total Children Is Unduplicated) 11 16 11.316667 $657.6100 $58.1100
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 204 214 1862.350808 $100566.9600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 11.114286 $903.8100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 15.142858 $1231.4100 $81.3200
TRAV -TRAVS Travel by mile 14 14 122.219049 $54.3900 $0.4500
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Subtotal (Total Children Is Unduplicated) 482 851 2523.847622 $128407.4900 $50.8800
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Total 873 2539.708733 $129234.1600 $50.8900
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Number of Children (Unduplicated) With at Least One Authorization 494