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: 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 945 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 9 9 5.533334 $205.8400 $37.2000
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Subtotal (Total Children Is Unduplicated) 9 9 5.533334 $205.8400 $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 2 2 0.450000 $26.1500 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 6.122222 $355.7600 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.588889 $34.2200 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 3.955555 $229.8500 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.455555 $142.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 17 24 17.572221 $995.5300 $56.6500
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 158 164 137.655555 $6882.7600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 16.685713 $834.2800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 231 239 177.671425 $8883.5400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 41 43 334.857148 $9041.1500 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 344 356 3323.512734 $179469.6800 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 144.685717 $11765.7900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 21 21 88.142859 $7167.7500 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 34 132.071431 $10740.0100 $81.3200
TRAV -TRAVS Travel by mile 7 7 79.000001 $35.1600 $0.4500
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Subtotal (Total Children Is Unduplicated) 377 912 4434.282583 $234820.1000 $52.9600
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Total 945 4457.388138 $236021.4800 $52.9500
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Number of Children (Unduplicated) With at Least One Authorization 385