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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2276 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 29 29 16.211111 $603.0500 $37.2000
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Subtotal (Total Children Is Unduplicated) 29 29 16.211111 $603.0500 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 15.000000 $679.8000 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 26 28 9.877780 $574.0100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 25 25 16.522224 $960.1200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 18 18 6.655557 $386.7600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 6.866668 $399.0300 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 39 20.333336 $1181.5900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.116667 $6.7800 $58.1300
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Subtotal (Total Children Is Unduplicated) 80 140 78.372232 $4362.4200 $55.6600
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.155556 $7.7800 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 268 276 223.798411 $11189.9100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 34 48.810319 $2440.5200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 450 465 264.392851 $13219.6300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.422222 $21.1100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 106 167 882.999983 $23841.0300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 668 710 4576.125356 $247110.8100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 112 166 492.357151 $40038.5500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.285714 $279.0800 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 3.071429 $200.0100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 70 103 300.785719 $24459.9400 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 14.857143 $967.4900 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 106 161 440.785724 $35844.7400 $81.3200
TRAV -TRAVS Travel by mile 19 20 131.614284 $58.5700 $0.4400
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Subtotal (Total Children Is Unduplicated) 775 2107 7384.461862 $399679.1700 $54.1200
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Total 2276 7479.045205 $404644.6400 $54.1000
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Number of Children (Unduplicated) With at Least One Authorization 815