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 687 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 1 1 0.144444 $5.3700 $37.1900
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Subtotal (Total Children Is Unduplicated) 1 1 0.144444 $5.3700 $37.1900
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.133333 $7.7500 $58.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.322222 $18.7200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 2.766667 $160.7700 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.466667 $27.1200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.166667 $125.9100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 3.233333 $187.8900 $58.1100
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Subtotal (Total Children Is Unduplicated) 13 18 10.088889 $573.4800 $56.8400
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 46 47 308.247617 $16645.3800 $54.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 12.000000 $975.8400 $81.3200
TRAV -TRAVS Travel by mile 5 5 17.714285 $7.8800 $0.4400
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Subtotal (Total Children Is Unduplicated) 441 668 704.380187 $35950.1300 $51.0400
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Total 687 714.613520 $36528.9800 $51.1200
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Number of Children (Unduplicated) With at Least One Authorization 452