Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 585 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 42 42 22.068251 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 22.068251 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.411111 $23.8900 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.494445 $28.7400 $58.1200
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Subtotal (Total Children Is Unduplicated) 3 4 0.905556 $52.6200 $58.1100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 56 12.522227 $626.1400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 0.422222 $21.1100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.155556 $7.7800 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.988889 $49.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.155556 $7.7800 $50.0100
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.011111 $50.5600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.911111 $45.5600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 6.857143 $185.1400 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 27 233.000001 $12582.0000 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 412 436 3323.996076 $39887.9500 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 5 5 32.142858 $2613.8500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 5.571429 $453.0700 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 2 2 15.000000 $1219.8000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 15.571429 $1266.2700 $81.3200
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Subtotal (Total Children Is Unduplicated) 443 539 3648.305608 $59016.4400 $16.1800
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Total 585 3671.279415 $59069.0600 $16.0900
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Number of Children (Unduplicated) With at Least One Authorization 478