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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 429 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 10.492062 $479.2700 $45.6800
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Subtotal (Total Children Is Unduplicated) 14 14 10.492062 $479.2700 $45.6800
Screening, Eval, and Assessment, Class # 02
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.738890 $42.9400 $58.1200
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.555556 $32.2900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.311112 $134.3000 $58.1100
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Subtotal (Total Children Is Unduplicated) 7 14 7.605558 $441.9700 $58.1100
EI Services, Class # 03
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 22.988890 $1149.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 6.358730 $317.9400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 31 46.677779 $2333.8900 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 17 163.428569 $4412.5700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 281 288 2714.642824 $146590.7400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 67.000001 $5448.4400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.714286 $372.1200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 10 10 53.857144 $4379.6600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 9.928572 $646.5500 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 61.514287 $5002.3400 $81.3200
TRAV -TRAVS Travel by mile 3 4 31.000000 $13.8000 $0.4500
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Subtotal (Total Children Is Unduplicated) 296 401 3183.111082 $170667.5000 $53.6200
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Total 429 3201.208702 $171588.7400 $53.6000
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Number of Children (Unduplicated) With at Least One Authorization 310