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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1197 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 24 24 23.946029 $1093.8400 $45.6800
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Subtotal (Total Children Is Unduplicated) 24 24 23.946029 $1093.8400 $45.6800
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 10.000000 $453.2000 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 8 2.911111 $169.1600 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 8.122222 $471.9800 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 11 3.144444 $182.7200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.122222 $65.2100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 5.672223 $329.6200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.133333 $65.8600 $58.1100
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Subtotal (Total Children Is Unduplicated) 38 52 32.105555 $1737.7500 $54.1300
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 81 49.946825 $2497.3500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 14.909524 $745.4800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 117 39.329367 $1966.4800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 60 60 365.857139 $9878.1600 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 662 682 5076.923791 $274153.9700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 5.285714 $285.4300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 58 225.217465 $18314.6900 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.071429 $395.3700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 32 33 124.857145 $10153.3900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 14.500000 $944.2300 $65.1200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 56 181.525401 $14761.6500 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 0.928572 $60.4600 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 10.214286 $665.1600 $65.1200
TRAV -TRAVS Travel by mile 11 12 69.857143 $31.0900 $0.4500
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Subtotal (Total Children Is Unduplicated) 724 1121 6186.423801 $334871.0100 $54.1300
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Total 1197 6242.475385 $337702.6000 $54.1000
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Number of Children (Unduplicated) With at Least One Authorization 756