Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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 7535 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 9 3.488889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 9 3.488889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 782 812 809.553425 $17373.0200 $21.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 778 809 806.553425 $13025.8400 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92558 OTOACOUSTIC EMISSIONS (SCREENING) 22 22 22.000000 $151.1400 $6.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 753 782 779.553425 $6174.0600 $7.9200
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 25 25 25.000000 $272.0000 $10.8800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 750 779 776.553425 $24702.1600 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 25 25.000000 $379.7500 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 752 780 777.553425 $17992.5900 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 16 22 40.557144 $2027.8600 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 25 26 25.611111 $1488.2600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 25 25 25.000000 $1452.7500 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 19.142857 $1112.3900 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 6.785714 $394.3200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 28 30 30.000000 $1743.3000 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 32 32 32.000000 $1859.5200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 41 48 398.247614 $23142.2000 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 7.000000 $406.7700 $58.1100
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Subtotal (Total Children Is Unduplicated) 866 4238 4611.111565 $114044.4700 $24.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.000000 $30000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 207 294 547.223429 $27361.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 60 95.093651 $4754.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 34 37 56.574605 $2828.7400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 157 250.184133 $12509.2300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1213 1622 14631.868556 $790121.6400 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 220 281 2182.134939 $177451.2400 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 335 433 2724.730205 $221575.0800 $81.3200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 307 396 3047.060341 $247787.0200 $81.3200
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Subtotal (Total Children Is Unduplicated) 1555 3288 23542.869859 $1514636.6000 $64.3400
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Total 7535 28157.470313 $1628681.0700 $57.8400
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Number of Children (Unduplicated) With at Least One Authorization 1573