Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 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 2831 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 8 8 12.863491 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 8 8 12.863491 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 50 58 44.658035 $2165.9300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 3.438889 $212.2100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.283333 $4.3000 $15.1900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $72.8400 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.865297 $39.2200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.377778 $159.5600 $115.8100
EXIT -EXIT COS Exit 2 2 1.002740 $50.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $162.4100 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3300 $60.1600
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 56 58 89.071227 $7213.0100 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 27.500000 $2226.9500 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 37 39 76.500000 $6194.9700 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 83 92 156.571227 $9381.7600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 31 32 63.500000 $3804.9200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 74 147.000000 $11904.0600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 20 28 56.000000 $4534.8800 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 4 0.375342 $21.8100 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 56 66 39.064788 $2270.0800 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 2 2.000000 $116.2200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 20 24 12.165980 $706.9600 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 6 8 3.471386 $201.7300 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.688889 $40.0300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.350685 $20.3800 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 30 38 18.118114 $1052.8700 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 13 15 10.897109 $633.2400 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.505556 $29.3800 $58.1200
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.394444 $22.9200 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 60 68 40.404826 $2347.9200 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 3 0.516666 $30.0200 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 7 8 1.839801 $106.9200 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 6 3.116438 $181.0900 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 4 2.249315 $130.7100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 7.356164 $427.4600 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.316667 $76.5100 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 4 2.505555 $145.5900 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 5 1.511112 $87.8200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 2 12.857143 $747.1300 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 2 0.505556 $29.3800 $58.1200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 306 707 866.991020 $59927.3400 $69.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 49 56 192.769624 $963848.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 62 65 100.372153 $5018.5800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 12 17.433333 $871.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 328 446 877.804726 $43890.0500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 5 8 15.599999 $780.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.333333 $58.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 213 253 516.276168 $25813.6900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 4.766665 $238.3300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 2 3.000000 $150.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.099999 $152.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 306 365 729.333302 $36466.5000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 2 3.000000 $150.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 6.300000 $157.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 324 410 3150.552386 $170129.8100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 42 49 358.285716 $19347.4200 $54.0000
INTR -T1013 INTERPRETER 22 35 76.250000 $3812.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 11 16 62.780952 $753.3700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 104 128 1018.209523 $82800.8400 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 3 5 39.000000 $3171.4800 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 0.142857 $11.6200 $81.3400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 5.285714 $429.8300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 54 63 439.685715 $35755.2700 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 0.142857 $11.6200 $81.3400
PHY -97110GT PT SESSION BY LICENSED PT 3 5 38.857143 $3159.8600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 5 52.428571 $3414.1500 $65.1200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.377778 $86.7500 $229.6200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.498630 $114.4800 $229.6000
SENS -V5264 EARMOLD 2 2 1.881278 $34.1100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 122 986.928573 $80257.0300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 10 77.857142 $6331.3500 $81.3200
TRAV -TRAVS Travel by mile 18 34 2110.528569 $939.1900 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 453 2116 10894.782706 $1488155.7900 $136.5900
-------------------------------------------------------------------------------------------------------------------------------------
Total 2831 11774.637217 $1548083.1300 $131.4800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 539