Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 09
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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2795 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 35 40 83.271428 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 40 83.271428 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.005556 $0.1100 $19.6700
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.005556 $0.1300 $23.8700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.005556 $0.0800 $14.7900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.005556 $0.0400 $7.2500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.005556 $0.1600 $29.1600
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.005556 $0.1200 $21.2000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.005556 $0.4900 $87.6300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.005556 $0.2500 $45.6800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.005556 $0.6500 $116.7200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 23.961905 $1198.0900 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 20 23 112.714285 $5635.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 24 36 136.726194 $6835.8400 $50.0000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 127 183 220.762311 $11038.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 103 140 155.784545 $3894.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 126 131 124.522103 $6226.1200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 1.488889 $37.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 86 86.276189 $4313.8000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.438889 $35.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 51 44.022102 $2201.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 98 102 116.696826 $5834.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 3.311112 $82.7800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 996 1392 10876.842862 $543841.9200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 8.142857 $407.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 127 174 1213.019046 $87288.8100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 2 12.857143 $925.2000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 101 142 1038.727382 $74746.8200 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.005556 $0.6400 $115.7100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.005556 $1.2900 $231.4300
SENS -V5264 EARMOLD 1 1 0.005556 $0.1000 $18.2700
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 214 298 2302.274599 $165671.6700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $442.0400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 3.142857 $226.1600 $71.9600
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Subtotal (Total Children Is Unduplicated) 1169 2719 16215.469237 $907216.3500 $55.9500
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Total 2795 16435.466859 $914052.1900 $55.6100
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Number of Children (Unduplicated) With at Least One Authorization 1192