Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 3946 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 35 37 35.494444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 37 35.494444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 45 47 27.922226 $1723.1000 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 50 54 46.304763 $703.3700 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 32 36 23.438889 $503.0000 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.711111 $18.5200 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 7.038889 $170.9000 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.572222 $12.4500 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 24 25 21.761111 $692.2200 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 49 52 35.422222 $538.0600 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 44 50 40.211114 $930.4900 $23.1400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 6.011111 $360.1900 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 22.000000 $1318.2400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 6.011111 $486.7800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 22.000000 $1781.5600 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 13 17 17.000000 $987.8700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 51 55 34.144448 $1984.1500 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 3 3 1.483334 $86.2000 $58.1100
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 9 4.538888 $263.7500 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 4 2.505556 $145.6000 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 23 25 18.238892 $1059.8800 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 2 0.505555 $29.3700 $58.1000
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.505556 $29.3800 $58.1200
PSTF -97164 PT RE-EVAL EST PLAN CARE 11 13 10.650000 $618.8700 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 27 32 19.633336 $1140.9100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.944444 $54.8800 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 2 0.505556 $29.3800 $58.1200
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 22 16.827779 $977.8700 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 1.011112 $58.7600 $58.1200
SPCH -92521 EVAL OF SPEECH FLUENCY 77 90 60.255559 $3501.4700 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 5 4.272222 $248.2600 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.505556 $29.3800 $58.1200
SPCH -92522 EVAL OF SPCH SOUND PROD 9 10 10.000000 $581.1000 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.505556 $29.3800 $58.1200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 62 71 47.161115 $2740.5500 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.061111 $119.7700 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 18 22 19.400001 $1127.3400 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.505556 $87.4900 $58.1100
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 16 19 326.142857 $18952.1600 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 2 13.000000 $755.4300 $58.1100
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Subtotal (Total Children Is Unduplicated) 474 731 882.708758 $45359.1300 $51.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 3 3.000000 $15000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 0.511111 $35.4400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 8.000000 $1852.9600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 104 143 133.920442 $6696.0600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 17 21 19.500000 $975.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 11 13 14.822223 $370.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 424 590 1706.026966 $85301.2700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 8 8 23.300001 $1165.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 196 265 708.047604 $35402.3100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 8 11 20.899999 $1045.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 95 118 329.176179 $16458.7600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 6 6 11.366666 $568.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.033333 $75.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 222 280 596.526972 $29826.2900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 7 13.799998 $689.9900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 989 1286 11959.019059 $645787.0000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 66 80 643.657143 $34757.4800 $54.0000
INTR -T1013 INTERPRETER 1 1 10.571429 $528.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 74 727.428568 $59154.5100 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 1.000000 $81.3200 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 25.285715 $2056.2300 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 17 21 195.428573 $12726.3000 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.714286 $632.6000 $65.1200
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 12.142857 $790.7500 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 45 60 595.747618 $48446.1900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 2.066667 $134.5800 $65.1200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 2 13.000000 $1057.1600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 124 151 1316.571426 $107063.6300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 2 11.571429 $940.9900 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 9 9 103.857143 $6763.1700 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 3 4 40.571429 $2642.0100 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 40.714285 $3310.8900 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 2 13.000000 $1057.1600 $81.3200
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Subtotal (Total Children Is Unduplicated) 1090 3178 19313.345788 $1123394.9900 $58.1700
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Total 3946 20231.548990 $1168754.1200 $57.7700
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Number of Children (Unduplicated) With at Least One Authorization 1128