Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 01
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 9369 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
CASE -CASE NON-TCM CASE MANAGEMENT 4 4 6.555556 $242.5600 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 106 122 461.723015 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 481 488 10934.938113 $404592.7400 $37.0000
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Subtotal (Total Children Is Unduplicated) 553 614 11403.216684 $404835.2900 $35.5000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 40 56 46.950763 $2277.1100 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.933333 $45.8200 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.0800 $9.0800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 14 14 14.011111 $1188.7000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 5 5 5.000000 $255.3500 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 82 82 164.000000 $8200.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.500000 $360.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 46.500000 $3487.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 8 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 132 133 249.500000 $13847.2500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 186 261 495.000000 $37125.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 4.452055 $227.2700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 5.285714 $269.8400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 11.000000 $561.5500 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 11.000000 $561.5500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 18 15.109590 $771.3500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 10.000000 $445.5000 $44.5500
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Subtotal (Total Children Is Unduplicated) 402 679 1162.742566 $74595.1500 $64.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 38 42.338965 $211694.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.033333 $1.6700 $49.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 9 7.633334 $381.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 13.000000 $930.9300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 19 20 28.688889 $6598.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 205 236 312.838376 $15641.9200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 136 149 138.961349 $3474.0400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 196 263 609.708722 $30485.4000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 10 17.333333 $433.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 95 175.311106 $8765.5300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.433334 $135.8400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 109 143 276.541262 $13827.0300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 11.176190 $279.4100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 151 200 370.041262 $18502.0300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 14.883334 $372.0900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1185 1593 12259.588854 $612979.5100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 69.580952 $3479.0600 $50.0000
INTR -T1013 INTERPRETER 102 126 778.432541 $38921.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1318 2349 16175.376937 $161753.7800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 92 689.076191 $49227.6000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.900000 $135.7400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 114 150 1153.667460 $82418.0100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.714286 $408.2300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 23.000000 $1314.6800 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 4 5 22.857142 $1632.9100 $71.4400
SENS -V5264 EARMOLD 4 4 7.304870 $131.4900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 148 196 1363.165869 $97384.5700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 48.142857 $3439.3300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 7.000000 $500.0800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714286 $1265.5100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 11 12 115.714286 $1606.1100 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 9.000000 $333.0000 $37.0000
TRAV -TRAVS Travel by mile 1317 2348 16231.776939 $7223.1400 $0.4400
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Subtotal (Total Children Is Unduplicated) 1360 8076 51003.936259 $1375728.1800 $26.9700
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Total 9369 63569.895509 $1855158.6300 $29.1800
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Number of Children (Unduplicated) With at Least One Authorization 1487