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: 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 453 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 13 13 11.766667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 11.766667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 3 4 3.544444 $414.0900 $116.8300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 50 60 42.149999 $2044.2700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 5 2.722222 $167.9900 $61.7100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 4.511111 $109.5300 $24.2800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $49.5900 $49.5900
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 11.273809 $510.9300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.755556 $87.5100 $115.8200
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
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Subtotal (Total Children Is Unduplicated) 65 83 66.957141 $3442.0200 $51.4100
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 2 2 2.022222 $96.9400 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 18 23 36.066666 $180333.0000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 152 172 150.258734 $7512.9500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 6 7.111111 $355.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.238889 $11.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 -1.450000 $-72.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 6 -3.055556 $-152.7800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 48 60 398.225395 $21504.1900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 9 41.984127 $2267.1500 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 15 24.700002 $2008.6200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 0.266667 $21.6900 $81.3300
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.766667 $49.9300 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 6 8 18.033334 $1466.4600 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 2 2 -5.571429 $-453.0700 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.071429 $5.8100 $81.2900
PHY -97110 PT SESSION BY LICENSED PT 10 10 76.750794 $6241.3700 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 5 7 24.720635 $2010.2900 $81.3200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 2 0.755556 $346.9900 $459.2500
SENS -V5264 EARMOLD 2 3 7.612699 $138.0200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 17 42.603176 $3464.4900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 16.004761 $1301.4900 $81.3200
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Subtotal (Total Children Is Unduplicated) 226 357 838.115879 $228458.5400 $272.5900
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Total 453 916.839687 $231900.5600 $252.9300
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Number of Children (Unduplicated) With at Least One Authorization 267