Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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 1805 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 6 7 4.444444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 7 4.444444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 3.066667 $45.0200 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 3.066667 $22.0800 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 3.066667 $88.6900 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 3.066667 $64.5200 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.252055 $11.4300 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.252055 $29.2000 $115.8300
OCTH -97165 OT EVAL LOW COMPLEXITY 9 10 10.000000 $514.1000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 9.000000 $462.6900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 5.000000 $257.0500 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 7.000000 $359.8700 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 57 59 59.300000 $2965.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 13 14 14.000000 $719.7400 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 10 10 12.066667 $620.3500 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 5.433333 $279.3300 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 25.142857 $1330.8100 $52.9300
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Subtotal (Total Children Is Unduplicated) 109 138 168.713635 $8232.5600 $48.8000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 3.066667 $153.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 8.600000 $430.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 259 368 1089.323811 $54466.2000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 7.666666 $383.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 164 223 712.690478 $35634.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 90 120 448.666667 $22433.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 162 196 594.000003 $29700.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 10 28.500001 $712.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.133333 $28.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 6.066667 $303.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 336 428 2766.299983 $138315.0400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 6.133333 $306.6700 $50.0000
INTR -T1013 INTERPRETER 4 4 33.419047 $1670.9600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 64 297.847618 $21433.1300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 4 11.066667 $796.3600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 21 27 165.285713 $9520.4700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 47 54 330.714288 $23798.1900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 16.266667 $1170.5500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 7 7 68.580952 $3947.5200 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 6.133333 $441.3500 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.825000 $131.3300 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 9.714286 $559.1600 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 1.022222 $18.5300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 105 131 721.207141 $51898.0700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 29.133333 $2096.4300 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.133333 $441.3500 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 1.033333 $14.4200 $13.9600
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Subtotal (Total Children Is Unduplicated) 478 1660 7373.530542 $401263.6500 $54.4200
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Total 1805 7546.688621 $409496.2100 $54.2600
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Number of Children (Unduplicated) With at Least One Authorization 493