Summary Report for FSPSAs Initiated During the Report Period Center: 51
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 303 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 7 7 15.649207 $714.8600 $45.6800
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Subtotal (Total Children Is Unduplicated) 7 7 15.649207 $714.8600 $45.6800
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 12 12 12.000000 $697.3200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 21.142857 $1228.6100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 11.142857 $647.5100 $58.1100
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Subtotal (Total Children Is Unduplicated) 27 28 51.285714 $2980.2100 $58.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.033333 $5166.5000 $4999.8400
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 3.033333 $75.8300 $25.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.033333 $50.8300 $25.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.433333 $110.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 4.142857 $207.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.633333 $15.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.642857 $82.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 76 542.404755 $29289.8900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 40.604760 $2192.6600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 45 192.219043 $15631.2700 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 -24.500000 $-1992.3400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 12 14 107.357142 $6991.0900 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.633333 $132.8200 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 1.000000 $65.1200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 30 32 175.576188 $14277.8700 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 2 2 10.714285 $871.2900 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 71 73 314.809517 $25600.3400 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 13.095238 $1064.9100 $81.3200
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Subtotal (Total Children Is Unduplicated) 195 268 1391.866640 $99834.0400 $71.7300
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Total 303 1458.801561 $103529.1000 $70.9700
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Number of Children (Unduplicated) With at Least One Authorization 209