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: 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 4119 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 8 9 7.144444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 9 7.144444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $206.7200 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 113 167 139.491267 $6765.3100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 25 26 29.344444 $1646.2200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 0.788889 $12.5000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.500000 $9.7600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.500000 $11.8400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.950000 $28.6300 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 53 58 49.496035 $1092.3800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.866667 $6.2400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.500000 $14.4600 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.500000 $22.5400 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.300000 $45.5700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 3.188889 $67.0900 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.366667 $22.3700 $61.0100
AUDE -92651 AEP HEARING STATUS DETER I&R 3 3 0.911111 $79.2100 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 2 2 0.777778 $58.4400 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 20 21 18.988889 $860.5800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.500000 $57.9100 $115.8100
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 190 301 255.970636 $11107.7500 $43.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 39 44 56.672222 $283361.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.166667 $1196.7100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 218 278 210.953176 $10547.6700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 20 13.438888 $671.9400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 75 94 124.976988 $6248.8700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 174 200 171.768251 $8588.4000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 7 8 7.022222 $351.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 96 120 112.650004 $5632.5200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 272 331 292.990480 $14649.5400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 3 3 1.361110 $68.0500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.444444 $36.1100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 512 649 3694.693644 $184734.6000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 52 59 365.002383 $18250.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 753 1693 6416.588104 $64165.8600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 40 240.034126 $17272.8500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 10 12 80.828573 $5816.4100 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 42 51 321.107934 $23106.9200 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.066667 $220.6800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 29 33 227.805556 $16392.8800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 4 12.500000 $899.5000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 44 53 315.232540 $22684.1100 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 4 11.780953 $847.7600 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 5.033333 $2311.3900 $459.2200
SENS -V5264 EARMOLD 4 4 6.766667 $122.6800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 25 168.828571 $12148.8900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.142857 $370.0800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 50 61 415.802387 $29921.1300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.123810 $944.3900 $71.9600
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Subtotal (Total Children Is Unduplicated) 774 3809 13308.315890 $731922.9600 $55.0000
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Total 4119 13571.430970 $743030.7100 $54.7500
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Number of Children (Unduplicated) With at Least One Authorization 780