Summary Report for FSPSAs Initiated During the Report Period Center: 53
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 63 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 12 12 19.261111 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 12 12 19.261111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 2.633334 $127.7200 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.488889 $11.8700 $24.2800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 5 5 3.122223 $139.5900 $44.7100
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 14 16 11.925397 $596.2700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 1.750000 $87.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 6.214286 $310.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.466667 $23.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.933333 $96.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 20 21 92.525395 $4996.3600 $54.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 0.977778 $79.5100 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 1 1 0.566667 $46.0800 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 41 46 118.359523 $6336.4400 $53.5400
-------------------------------------------------------------------------------------------------------------------------------------
Total 63 140.742857 $6476.0300 $46.0100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 55