Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Statewide
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: 01-01-21 and 03-31-21 Date of Report: 05-04-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 25630 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 3 3 3.311112 $122.5100 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 451 524 1868.349208 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 256.000000 $9472.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 456 529 2127.660320 $9594.5100 $4.5100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 206 255 264.366628 $12821.8100 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 405 417 456.005893 $10711.5700 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.144444 $29.7400 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $71.1000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.144444 $10.3900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.144444 $31.8500 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 26.714286 $2266.4400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.500000 $25.5400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $33.4000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.988889 $228.7200 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 24 28 25.815298 $1290.7700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 5 9.000000 $450.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 385 386 614.205645 $30710.2700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.500000 $337.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 9.005479 $499.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.500000 $787.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.250000 $63.8100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.016667 $0.8500 $51.1500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.305556 $66.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 26 10.972223 $560.1400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.011111 $0.5700 $51.0000
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 10 5.994445 $306.0200 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 28 11.405557 $582.2600 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 0.500000 $22.2800 $44.5500
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Subtotal (Total Children Is Unduplicated) 1078 1223 1519.491009 $65740.5800 $43.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 26 37.702207 $188511.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 6.766667 $338.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 12 12.322221 $616.1100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.005479 $0.3900 $71.8900
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.144444 $493.2100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 769 1044 1085.157384 $54257.9800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 53 56 53.091213 $2654.5700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 136 148 135.986363 $3399.6800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2298 2935 5555.516666 $277775.6800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 105 118 198.903968 $9945.1900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 254 312 391.106346 $9777.6500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1747 2304 3665.607936 $183280.3500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 110 124 195.676188 $9783.8100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 126 242 307.129364 $7678.2300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 860 1120 1827.298397 $91364.8600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 80 92 149.214282 $7460.7100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 47 106 131.961106 $3299.0200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2604 3139 4857.193242 $242859.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 135 152 202.116669 $10105.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 273 333 403.946822 $10098.6600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 1 1.933333 $0.0000 $0.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 2 9.321428 $233.0400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 5.857143 $292.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 280 1974.815872 $98740.7100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 12 88.871429 $4443.5700 $50.0000
INTR -T1013 INTERPRETER 224 298 1628.205803 $81410.2700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4863 7935 53014.034952 $530139.8300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 48 272.309524 $19453.7500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 6.428571 $459.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 11 42.796824 $2447.9800 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 7.714286 $551.1100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 34 39 264.409521 $18889.4000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 2 12.857143 $734.9100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 3 2.011111 $130.7200 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.988889 $681.4700 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.144444 $65.8500 $455.8600
SENS -V5264 EARMOLD 2 2 1.133333 $20.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 66 487.250001 $34809.1000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 17.785713 $1270.6200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.000000 $142.8800 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 5 6 11.536508 $426.8500 $37.0000
TRAV -TRAVS Travel by mile 1465 2892 213336.101792 $94934.5500 $0.4400
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Subtotal (Total Children Is Unduplicated) 7690 23878 290410.354584 $2004053.3600 $6.9000
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Total 25630 294057.505913 $2079388.4600 $7.0700
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Number of Children (Unduplicated) With at Least One Authorization 8518