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: 10-01-24 and 12-31-24 Date of Report: 03-31-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1390 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 17 17 7.700001 $286.4400 $37.2000
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Subtotal (Total Children Is Unduplicated) 17 17 7.700001 $286.4400 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 5.000000 $226.6000 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 6 1.727778 $100.4000 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 16 16 11.327778 $658.2600 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 2.105554 $122.3400 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 5.516667 $320.5800 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 19 19 11.244444 $653.4100 $58.1100
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Subtotal (Total Children Is Unduplicated) 40 63 38.922221 $2197.8100 $56.4700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 0.711112 $35.5600 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 201 209 191.783331 $9589.1600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 22 41.484922 $2074.2500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 343 351 220.015070 $11000.7200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 59 62 457.214282 $12344.8000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 470 496 3721.071430 $200937.8300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 60 272.285717 $22142.2900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 37 37 141.857145 $11535.8300 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 10.000000 $651.2000 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 55 180.857146 $14707.3100 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 19.142857 $1246.5900 $65.1200
TRAV -TRAVS Travel by mile 11 13 66.861905 $29.7500 $0.4500
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Subtotal (Total Children Is Unduplicated) 524 1310 5323.284917 $286295.2700 $53.7800
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Total 1390 5369.907139 $288779.5200 $53.7800
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Number of Children (Unduplicated) With at Least One Authorization 539