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 715 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 18 18 14.303173 $653.3600 $45.6800
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Subtotal (Total Children Is Unduplicated) 18 18 14.303173 $653.3600 $45.6800
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $181.2800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 8 3.022224 $175.6300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 9.000000 $522.9900 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 -0.105555 $-6.1300 $58.0800
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 5.000000 $290.5500 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 7.700001 $447.4500 $58.1100
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Subtotal (Total Children Is Unduplicated) 22 41 28.616670 $1611.7700 $56.3200
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
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 28 237.428567 $6410.5800 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 433 447 4102.495189 $221534.8300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 21 146.285715 $11895.9500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 5 5 27.071430 $1762.9000 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 15 15 101.642858 $8265.5900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 15.142858 $986.1100 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 22 22 111.371431 $9056.7300 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 6.214286 $404.6800 $65.1200
TRAV -TRAVS Travel by mile 8 9 63.023810 $28.0500 $0.4500
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Subtotal (Total Children Is Unduplicated) 458 656 4943.231707 $266973.2100 $54.0100
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Total 715 4986.151550 $269238.3500 $54.0000
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Number of Children (Unduplicated) With at Least One Authorization 476