Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1857 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 7.088888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 7.088888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.000000 $32.3000 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.000000 $63.6200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.000000 $46.2800 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.000000 $135.9600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $231.6200 $115.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 11.000000 $639.2100 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 11 11.000000 $639.2100 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 7.000000 $406.7700 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 7.000000 $406.7700 $58.1100
SCREEN-T1023 SCREENING 29 31 31.000000 $1673.3800 $53.9800
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 13.000000 $755.4300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 8 8.000000 $464.8800 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 2.000000 $116.2200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 13 16 89.961904 $5227.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 92 115 194.961904 $10971.4000 $56.2700
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 8.133333 $406.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 271 393 1272.516676 $63625.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 177 212 768.600002 $38430.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 82 123 509.733340 $25486.7000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 128 154 504.533338 $25226.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 4.500001 $112.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 423 573 3165.569044 $170940.8600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 11 57.371428 $3098.0600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 68 82 450.009519 $36594.7600 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 7.285714 $592.4700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 3 3 21.695238 $1412.8000 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 10.857143 $707.0100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 63 73 391.421432 $31830.4400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 6 8 29.971429 $2437.2800 $81.3200
PHY -97110HM PT SESSION BY PT ASST 13 16 128.561906 $8371.9600 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 2 3 14.428571 $939.5800 $65.1200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 2 2 1.355555 $24.5800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 65 349.023807 $28382.5900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 31.819047 $2587.5300 $81.3200
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Subtotal (Total Children Is Unduplicated) 532 1734 7732.386523 $442817.6600 $57.2700
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Total 1857 7934.437315 $453789.0500 $57.1900
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Number of Children (Unduplicated) With at Least One Authorization 551