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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1873 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 6.622222 $246.3500 $37.2000
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Subtotal (Total Children Is Unduplicated) 18 18 6.622222 $246.3500 $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 6 6 1.922222 $111.7000 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.466667 $27.1200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 5.666668 $329.3000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 1.633333 $94.9100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 10 10 5.911113 $343.5100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 19 20 7.822224 $454.5600 $58.1100
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Subtotal (Total Children Is Unduplicated) 35 55 25.422227 $1451.7300 $57.1000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 14 3.455558 $172.7900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 276 289 206.260312 $10312.9800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 31 52.153970 $2607.7100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 384 400 238.230149 $11911.4700 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 110 152 693.000017 $18711.0300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 559 588 4020.231787 $217092.4500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 94 119 299.332548 $24341.5300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 53 64 161.142865 $13104.0300 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 137 342.307947 $27836.2800 $81.3200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 1.500000 $97.6800 $65.1200
TRAV -TRAVS Travel by mile 5 5 34.000001 $15.1300 $0.4500
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Subtotal (Total Children Is Unduplicated) 616 1800 6051.615154 $326203.0700 $53.9000
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Total 1873 6083.659603 $327901.1500 $53.9000
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Number of Children (Unduplicated) With at Least One Authorization 629