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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4336 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 40 45 32.611113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 45 32.611113 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 18 18 24.714286 $1376.8300 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 16 17 22.286508 $523.7300 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 20 20 18.822222 $442.3200 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 12.988889 $189.3800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 15.377778 $361.3800 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 28 17.666666 $172.9600 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 12 12 12.000000 $117.4800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 31 33 23.744444 $681.9400 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 14 14 13.377778 $598.7900 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $169.6800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $102.1400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 61 67 60.144444 $824.5800 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 45 45 81.306349 $1698.4900 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 5.000000 $225.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 35 35 55.850000 $2792.5000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 38.000000 $2109.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 17 34.000000 $2550.0000 $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 15 18 16.483334 $841.4800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 2.394444 $122.2300 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 12.857143 $656.3600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 10 2.900001 $148.0500 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 62 71 64.857689 $3311.0000 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.500000 $25.5300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 11 11.500000 $587.0800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 3.327778 $169.8800 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 36 42 28.696825 $1464.9700 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 7.855554 $401.0200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 15 16 17.533333 $895.0800 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.500000 $25.5300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 86 102 81.581083 $4164.7200 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.488889 $76.0100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 5 5.000000 $255.2500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 4 4.000000 $204.2000 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 25 29 24.755555 $1102.8600 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.500000 $22.2800 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 4 23.571428 $1239.1500 $52.5700
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Subtotal (Total Children Is Unduplicated) 418 710 757.582420 $31105.1400 $41.0600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 10.847619 $542.3800 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 7.714286 $531.2100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 27 31 67.206350 $4627.8300 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 13 14 20.188889 $4643.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 193 259 159.835750 $7991.8900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 10 10.104761 $252.6200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 551 750 1984.845232 $99242.2800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 3 4 13.933333 $696.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 5 14.066666 $351.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 267 331 749.935716 $37496.8000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 9.000000 $225.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 92 118 273.640945 $13682.0500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.433333 $10.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 275 337 737.283329 $36864.1500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 6.428571 $321.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.366667 $109.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 30.466666 $1523.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1021 1312 12019.094866 $600954.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 19 82.285715 $4114.2800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 91 738.876194 $52785.2700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 6 60.285714 $4306.8100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 12.857143 $918.5100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 43 58 502.142856 $35873.0700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 23.571428 $1683.9500 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.688889 $314.1400 $456.0100
SENS -V5264 EARMOLD 1 1 1.377778 $24.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 147 184 1410.428571 $100760.9600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 50.714286 $3623.0200 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 11.285714 $806.2500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 5 7 45.952382 $3282.8300 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 9 11 89.571426 $1243.2500 $13.8800
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Subtotal (Total Children Is Unduplicated) 1114 3581 19152.431075 $1019954.1300 $53.2500
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Total 4336 19942.624608 $1051059.2700 $52.7000
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Number of Children (Unduplicated) With at Least One Authorization 1159