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: 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 1614 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 18.342063 $682.3200 $37.2000
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Subtotal (Total Children Is Unduplicated) 29 29 18.342063 $682.3200 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 10 10.000000 $453.2000 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 16 19 4.966668 $288.6200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 4.705557 $273.4500 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 11 13 4.933334 $286.6800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 15 16 4.244448 $246.6700 $58.1100
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Subtotal (Total Children Is Unduplicated) 43 68 30.850007 $1664.8300 $53.9700
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 123 124 150.460310 $7522.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 34.798414 $1739.9300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 180 180 171.350788 $8567.5100 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 83 128 475.714302 $12844.2600 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 697 717 5925.370668 $319970.0300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.142857 $493.7200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 86 128 293.999992 $23908.0100 $81.3200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 3.071429 $200.0100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 54 82 176.428566 $14347.1300 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $725.6300 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 126 230.423802 $18738.0000 $81.3200
TRAV -TRAVS Travel by mile 12 14 86.665080 $38.5700 $0.4500
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Subtotal (Total Children Is Unduplicated) 780 1517 7568.569065 $409095.7600 $54.0500
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Total 1614 7617.761135 $411442.9100 $54.0100
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Number of Children (Unduplicated) With at Least One Authorization 798