Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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: 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 1739 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 56 66 2300.322223 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 4264.777778 $194815.0500 $45.6800
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Subtotal (Total Children Is Unduplicated) 65 75 6565.100001 $194815.0500 $29.6700
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
EXIT -EXIT COS Exit 1 2 2.000000 $100.0000 $50.0000
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 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 1.000000 $59.9200 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 21 21 42.000000 $3401.1600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1457.6400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $599.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $359.5200 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 12 13 4.160426 $241.7600 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 9 6.527778 $379.3300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 1.293759 $75.1800 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.377778 $5.7100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 20 19.753283 $1147.8600 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 62 110 149.113024 $10631.7700 $71.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 10 10.400000 $520.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.211111 $30.2800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 248 297 205.577757 $10278.7900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 5 1.977777 $98.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 171 208 258.902378 $6472.5500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 107 225 163.633325 $8181.6300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.277778 $13.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 57 125 182.655553 $4566.3800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 61 38.377771 $1918.8600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 17 40 40.800002 $1020.0100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 215 256 181.855532 $9092.6600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 5 5.111111 $255.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 158 194 250.300001 $6257.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 32 35 214.785711 $11598.4500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 20.857143 $1126.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 14 95.242857 $7745.1600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 15 16 189.571427 $12344.9200 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 7 7 77.714285 $6319.7300 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 6 59.000000 $3842.0800 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 0.377778 $6.8500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 34 281.923807 $22926.0800 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 9.714285 $789.9700 $81.3200
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Subtotal (Total Children Is Unduplicated) 404 1554 2298.267389 $126297.3400 $54.9500
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Total 1739 9012.480414 $331744.1600 $36.8100
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Number of Children (Unduplicated) With at Least One Authorization 467