Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3286 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 30 34 31.796028 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 30 34 31.796028 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 4 5 8.000000 $451.9200 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 4 3.544444 $69.8600 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 18 19 25.544444 $600.0400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 10 8.544444 $118.5100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 13 14 12.088888 $286.5000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 14 9.350000 $84.9000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 21 17.283333 $480.9900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 6 6 4.544444 $174.8200 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 10.155555 $861.5900 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 6 6 5.544444 $283.1500 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 52 52.684920 $879.8400 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 23 24 23.454110 $525.3700 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.252055 $191.3400 $45.0000
EXIT -EXIT EXIT ASSESSMENT 126 126 191.977301 $9598.8500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.057534 $4.3200 $75.0900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.057534 $114.2000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 26 18.471230 $1025.1700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 19 4.471230 $335.3600 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 1.761111 $89.9000 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 2 0.511111 $26.0900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 12 12 12.655556 $646.0700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 70 73 77.195442 $3940.8200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 4.450000 $227.1700 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 9 8.488889 $433.3600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 31 32 29.847617 $1523.7100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 13.022222 $664.7800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 82 91 77.974578 $3980.5900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 5.000000 $255.2500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 5 5 4.133333 $211.0100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 17 19 24.819047 $1105.6900 $44.5500
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Subtotal (Total Children Is Unduplicated) 386 642 682.884816 $30646.4300 $44.8800
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 6.285714 $450.1200 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 20 20 25.452381 $1822.6500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 11.370777 $2615.3100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 111 155 152.834136 $7641.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 21 24 41.932939 $1048.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 364 466 1492.229783 $74611.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 5 6.866667 $171.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 159 196 483.619060 $24181.0300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 3.066667 $76.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 74 96 255.100005 $12755.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 160 197 528.700018 $26435.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 13.971428 $349.2800 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.400000 $70.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 879 1097 10578.703635 $528935.6100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 51.571428 $2578.5800 $50.0000
INTR -T1013 INTERPRETER 4 5 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 65 84 832.619042 $59482.3500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 36.571428 $2612.6600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 14.142857 $1010.3700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 46 60 683.857141 $48854.7900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 2 13.142857 $938.9300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 26.285714 $1877.8500 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.133333 $60.7800 $455.8900
SENS -V5264 EARMOLD 1 2 6.000000 $108.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 105 139 1300.661898 $92919.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 48.571428 $3469.9400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 3 10.714286 $765.4300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 14 16 168.080953 $12007.7100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 103.000001 $1429.6400 $13.8800
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Subtotal (Total Children Is Unduplicated) 930 2610 16907.147480 $909793.5400 $53.8100
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Total 3286 17621.828324 $940439.9700 $53.3700
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Number of Children (Unduplicated) With at Least One Authorization 971