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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 9914 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 138 151 319.414283 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 3.444445 $128.1400 $37.2000
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Subtotal (Total Children Is Unduplicated) 140 153 322.858728 $128.1400 $0.4000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 50 60.629617 $2940.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 17.752382 $995.9100 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 13 32.714286 $638.2500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 6 16.857143 $399.0100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 7 17.857143 $262.1400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 7 17.857143 $394.1100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 6 16.857143 $121.3700 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 2.466667 $25.7800 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 6 16.857143 $487.5100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 6 16.857143 $759.9200 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 6 16.857143 $232.8000 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 15 17 51.227789 $1077.8300 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 1.000000 $75.1300 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.252055 $102.0700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 11.680626 $1352.7400 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 4.016667 $200.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 64 65 126.285714 $9471.4300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 24 24 47.500000 $3562.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 28.000000 $2100.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 44 44 83.785714 $6283.9300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 183 187 369.000000 $20479.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 53 54 105.571429 $5859.2100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 231 307 606.000000 $45450.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 80 102 201.071429 $15080.3600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 9.000000 $462.6900 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 5 5.491325 $82.9700 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $359.8700 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.947554 $202.9400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.079452 $55.5000 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 8 72.428572 $3833.6500 $52.9300
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Subtotal (Total Children Is Unduplicated) 520 1035 2068.901279 $130262.3800 $62.9600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 40 42 64.176127 $320880.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 4.457991 $222.9000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 16 19 37.823483 $8760.6800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 276 310 355.397683 $17769.8800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 16 20 5.061648 $253.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 42 42 42.195957 $1054.9000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 245 305 710.752392 $35537.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 27 35 86.038892 $4301.9600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 15 17 29.409524 $735.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 84 216.744449 $10837.2600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 11 14 26.700000 $1335.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 7 12.566668 $314.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 109 132 288.507698 $14425.4500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 16 20 44.516669 $2225.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 7.333334 $183.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 174 215 572.570643 $28628.5700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 17 23 40.122223 $2006.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 8 17.733334 $443.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 136 163 1257.204756 $62860.2800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1248 1595 13166.633317 $658332.0400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 150 193 1408.457138 $70422.9000 $50.0000
INTR -T1013 INTERPRETER 148 180 670.297620 $33514.9000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1566 2438 19050.934099 $190509.4600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 42 292.828567 $21071.9700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 24.714286 $1778.4400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 120 155 1231.871421 $88645.5400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 50.857143 $3659.6800 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 4 4 48.714286 $3505.4800 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 5 2.970777 $341.0800 $114.8100
SENS -V5264 EARMOLD 5 7 5.660883 $102.6300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 124 149 1246.009519 $89662.8600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 16 18 131.307935 $9448.9200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 3 36.714285 $2641.9700 $71.9600
TRAV -TRAVS Travel by mile 1570 2466 19155.503145 $8524.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 1659 8726 60342.787892 $1694938.2100 $28.0900
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Total 9914 62734.547899 $1825328.7300 $29.1000
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Number of Children (Unduplicated) With at Least One Authorization 1823