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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3351 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 14 14 16.611110 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 16.611110 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 100 134 92.148550 $4469.1900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 14 15 12.083333 $673.1600 $55.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.666667 $15.6700 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.733333 $10.6900 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 7 7 4.944444 $116.1900 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.733333 $7.1800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.733333 $21.0600 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 9 9 6.077778 $515.6400 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 4 2.511111 $34.4300 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 4.250000 $88.7800 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 11 6.855556 $308.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 4.055556 $466.3900 $115.0000
EXIT -EXIT EXIT ASSESSMENT 3 3 4.000000 $200.0000 $50.0000
SCREEN-T1023 SCREENING 3 3 2.411112 $120.5600 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.0800 $51.0600
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Subtotal (Total Children Is Unduplicated) 144 203 142.381884 $7056.5200 $49.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 36 46.285387 $231426.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.922223 $46.1200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 1.988889 $99.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 8 8 2.847184 $196.0500 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 10 11 6.033332 $1387.6400 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 133 168 94.302176 $4715.0800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 98 119 80.322226 $4016.1300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 61 70 97.198407 $4859.9000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 81 107 134.511105 $6725.5300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 101 116 109.164276 $5458.1800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 97 109 113.594439 $5679.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.200000 $55.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 65 79.125398 $3956.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 43 47 43.361114 $2168.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 131 144 144.994440 $7249.6900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 131 151 148.550788 $7427.5200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 5.511110 $137.7800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 250 1220.968247 $61048.4300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 419 519 2879.747828 $143987.4500 $50.0000
INTR -T1013 INTERPRETER 1 2 10.071429 $503.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 405 799 2672.038084 $26720.3900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 51 254.256346 $18164.0800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 11 12 64.510317 $4608.6200 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 4 5 21.942857 $1567.6000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 66 77 449.809516 $32134.4100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 31 45 174.326986 $12453.9400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 10 13 58.434920 $4174.5900 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 12 14 49.478571 $3534.7500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 43 60 246.466662 $17607.5700 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 3.800000 $1732.8000 $456.0000
SENS -V5264 EARMOLD 3 3 2.788889 $50.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 39 153.406350 $10959.3500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 11.971429 $855.2400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 5 6 10.999999 $785.8300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 52 64 334.675395 $23909.2000 $71.4400
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Subtotal (Total Children Is Unduplicated) 718 3134 9730.606319 $650402.5700 $66.8400
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Total 3351 9889.599313 $657459.1000 $66.4800
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Number of Children (Unduplicated) With at Least One Authorization 727