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 1647 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
----------------------------------------------------------------------------
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 1 1 0.244444 $15.0800 $61.7000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 5.033333 $76.4600 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.505556 $10.8500 $21.4600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.011111 $8.0100 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.811111 $57.6100 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 0.794445 $12.0700 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 4 1.322223 $30.6000 $23.1400
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 2 2.000000 $116.2200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 3.361112 $195.3200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 2 2.000000 $116.2200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.505556 $87.4900 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 2 2.000000 $116.2200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 4.083334 $237.2900 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.122222 $65.2100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 4.166667 $242.1300 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.388889 $80.7100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.000000 $290.5500 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 31 45 38.350003 $1816.1400 $47.3600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $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 195 264 707.847604 $35392.3100 $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 54 68 675.628573 $36483.9700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 26.000000 $1404.0000 $54.0000
INTR -T1013 INTERPRETER 1 1 10.571429 $528.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 10 123.428571 $10037.2100 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 13.000000 $846.5600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 5 6 85.000000 $6912.2000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 84.285714 $6854.1200 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.000000 $520.9600 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 13.000000 $846.5600 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 24.285714 $1974.9100 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 526 1565 4645.487051 $245438.3500 $52.8300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1647 4719.331498 $247254.4900 $52.3900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 562