Summary Report for FSPSAs Ending During the Report Period Center: 04
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending 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 577 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 19.933330 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 19.933330 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.611111 $35.5100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.466667 $27.1200 $58.1100
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Subtotal (Total Children Is Unduplicated) 3 4 1.077778 $62.6300 $58.1100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 64 14.283337 $714.1900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 0.038889 $1.9500 $50.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 2.077777 $103.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.033333 $151.6700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.100000 $5.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 15.714286 $424.2800 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 30 30 221.571429 $11964.8600 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 402 419 2868.617456 $34423.4100 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 18.714286 $1521.8500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 7.714286 $627.3300 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 2 2 7.285714 $592.4700 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 13.857143 $1126.8600 $81.3200
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Subtotal (Total Children Is Unduplicated) 429 531 3173.007936 $51657.7400 $16.2800
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Total 577 3194.019044 $51720.3800 $16.1900
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Number of Children (Unduplicated) With at Least One Authorization 470