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: 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 304 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 5 5 4.600000 $210.1300 $45.6800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5 5 4.600000 $210.1300 $45.6800
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 3 3.000000 $161.5400 $53.8500
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 44 57.458734 $2872.9600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 10.330159 $516.5100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 54 56 64.766670 $3238.3500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 175 182 1640.709505 $88598.3800 $54.0000
TRAV -TRAVS Travel by mile 8 9 63.023810 $28.0500 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 220 296 1836.288878 $95254.2400 $51.8700
-------------------------------------------------------------------------------------------------------------------------------------
Total 304 1843.888878 $95625.9100 $51.8600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 226