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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1162 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 23 23 15.980951 $594.4900 $37.2000
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Subtotal (Total Children Is Unduplicated) 23 23 15.980951 $594.4900 $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 7 9 1.950002 $113.3300 $58.1200
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 3.466668 $201.4600 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 9 3.888890 $225.9900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 2.994448 $174.0300 $58.1200
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Subtotal (Total Children Is Unduplicated) 27 40 18.300008 $999.5100 $54.6200
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 78 88.703169 $4435.1400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 28.155557 $1407.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 122 119.965076 $5998.2400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 68 105 389.571443 $10518.4100 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 481 496 4054.399232 $218937.5700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.142857 $493.7200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 65 100 209.142849 $17007.4400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 46 69 148.642852 $12087.6100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 11.142857 $725.6300 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 103 185.923802 $15119.2700 $81.3200
TRAV -TRAVS Travel by mile 9 11 69.379365 $30.8700 $0.4500
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Subtotal (Total Children Is Unduplicated) 549 1099 5314.169059 $286761.6700 $53.9600
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Total 1162 5348.450018 $288355.6600 $53.9100
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Number of Children (Unduplicated) With at Least One Authorization 564