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 616 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 2.361112 $87.8400 $37.2000
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Subtotal (Total Children Is Unduplicated) 6 6 2.361112 $87.8400 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 6 1.838889 $106.8600 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 1.961111 $113.9600 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.088889 $5.1700 $58.1200
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Subtotal (Total Children Is Unduplicated) 11 15 6.888889 $374.7300 $54.4000
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 247 252 2175.971439 $117502.4600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 6 31.857144 $2590.6100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 24.714286 $2009.7700 $81.3200
TRAV -TRAVS Travel by mile 12 14 86.665080 $38.5700 $0.4500
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Subtotal (Total Children Is Unduplicated) 403 595 2675.817461 $139971.8100 $52.3100
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Total 616 2685.067462 $140434.3900 $52.3000
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Number of Children (Unduplicated) With at Least One Authorization 408