Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 54
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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2582 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 19 22 23.104762 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 22 23.104762 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 6 6 5.644445 $659.4500 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 2 2 1.222222 $142.7900 $116.8300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 92 117 99.473810 $4824.4800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 21 23 23.438889 $1446.4100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $30.3800 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $21.4600 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $26.0400 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $32.3000 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 52 57 41.933333 $1018.1400 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 2.500000 $79.5300 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $99.1800 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $30.3800 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $46.2800 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 35 38 17.155556 $777.4900 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.700000 $196.8800 $115.8100
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Subtotal (Total Children Is Unduplicated) 188 263 207.068255 $9447.0200 $45.6200
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 15 15 9.938889 $476.4700 $47.9400
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.000000 $47.9400 $47.9400
AACFIT-92609TLGT AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.444444 $21.3000 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 45 52 75.866667 $379333.5000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 12.857143 $891.6400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.688889 $391.1800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 229 274 234.511507 $11725.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 13 11.322222 $566.1100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 95 128 150.352376 $7517.6000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.500000 $25.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 177 202 236.907938 $11845.4100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 2.433333 $60.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 112 139 156.382543 $7819.1400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 251 310 331.655548 $16582.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 14 6.900000 $172.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 11 149.142859 $4026.8500 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 542 718 4262.703190 $230185.7600 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 45 55 337.142858 $18205.7000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 53 350.052381 $28466.2900 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 4 4 26.357143 $2143.3600 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.071429 $5.8100 $81.2900
OCCT -97530HM OT SESSION BY OT ASST 9 10 35.857143 $2335.0100 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 43 51 283.030158 $23016.0100 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 23 27 213.261905 $17342.4500 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.000000 $243.9600 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 14 18 104.500000 $6805.0300 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 26 33 153.942859 $12518.6400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 32.142857 $2613.8500 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 36 47 206.677777 $16807.0100 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 18.142857 $1475.3700 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.200000 $45.9200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.500000 $1607.2700 $459.2200
SENS -V5264 EARMOLD 5 6 10.433333 $189.1600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 53 322.398417 $26217.3900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 32.499999 $2642.9100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 26 32 117.296826 $9538.5700 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 24.642858 $2003.9500 $81.3200
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Subtotal (Total Children Is Unduplicated) 817 2297 7920.758348 $845982.5900 $106.8100
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Total 2582 8150.931365 $855429.6100 $104.9500
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Number of Children (Unduplicated) With at Least One Authorization 829