Summary Report for FSPSAs Initiated During the Report Period Center: 03
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 223 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 63 63 36.387303 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 63 63 36.387303 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 5.000000 $242.5000 $48.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 2.816667 $163.6800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.472222 $143.6600 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 2.788888 $162.0600 $58.1100
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Subtotal (Total Children Is Unduplicated) 18 21 13.077777 $711.9000 $54.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 3.922222 $196.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 37 59.199998 $2959.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 38.644445 $1932.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 24 28.088888 $1404.4400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 28 33 200.766662 $10841.4200 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 6 34.092064 $2772.3700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 3 3 23.452381 $1907.1600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 46.247619 $3760.8700 $81.3200
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Subtotal (Total Children Is Unduplicated) 105 139 435.414279 $30774.5900 $70.6800
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Total 223 484.879359 $31486.4800 $64.9400
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Number of Children (Unduplicated) With at Least One Authorization 169