Summary Report for FSPSAs Ending During the Report Period Center: 57
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1406 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 14 14 6.688890 $248.8300 $37.2000
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Subtotal (Total Children Is Unduplicated) 14 14 6.688890 $248.8300 $37.2000
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 3 3 0.788888 $45.8400 $58.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 7.455556 $433.2400 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.800000 $46.4900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 15.273810 $887.5600 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 15 15 6.850000 $398.0500 $58.1100
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Subtotal (Total Children Is Unduplicated) 31 47 35.490476 $2011.1900 $56.6700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 8 1.561113 $78.0700 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 229 235 157.934934 $7896.7900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 21 24.984126 $1249.2000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 342 350 181.938112 $9096.9800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 65 70 392.571431 $10599.4300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 484 498 3292.260297 $177782.1600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 59 190.777779 $15514.0100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 34 35 119.357143 $9706.1000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 62 193.642856 $15747.0100 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.071429 $460.4900 $65.1200
TRAV -TRAVS Travel by mile 5 5 17.714285 $7.8800 $0.4400
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Subtotal (Total Children Is Unduplicated) 549 1345 4579.813505 $248138.1200 $54.1800
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Total 1406 4621.992871 $250398.1300 $54.1800
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Number of Children (Unduplicated) With at Least One Authorization 564