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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 10292 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 124 130 167.863491 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 124 130 167.863491 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 50 62 73.255646 $3552.9300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 26 27 27.744292 $1556.4600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 19 21 70.266666 $1113.0200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 4.266667 $83.2400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.266667 $53.6500 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 3.266667 $47.9600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 11.200000 $247.1800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 17.200000 $151.5300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 12.400000 $358.6100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 4 5.600000 $252.4500 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 2.266667 $31.3000 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 21 21 39.124854 $823.1900 $21.0400
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 3.333333 $202.4300 $60.7300
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 3 2.733333 $166.7300 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.153425 $52.2700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 1.682192 $194.8200 $115.8100
EXIT -EXIT COS Exit 70 74 54.266440 $2713.3100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.142857 $10.7200 $75.0200
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 12 24.000000 $1800.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 9 18.000000 $999.0000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 27 28 54.500000 $4087.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 41 82.000000 $6150.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 37 37 72.500000 $5437.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 4 4 7.500000 $562.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 222 229 454.505479 $25225.0600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 77 81 162.000000 $8991.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 256 313 623.505479 $46762.9100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 60 73 146.000000 $10950.0000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 12.714286 $688.7300 $54.1700
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 12.000000 $616.9200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 7.333333 $377.0100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 11 11 24.142857 $1241.1900 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.754991 $193.0400 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 5 7.831964 $118.3400 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 16 16 29.398413 $1511.3800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 6.857143 $352.5200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 4.336987 $222.9700 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.183562 $9.4400 $51.4200
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 66.419047 $3414.6100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 11.857143 $609.5700 $51.4100
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Subtotal (Total Children Is Unduplicated) 631 1183 2231.510390 $136887.9700 $61.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 47 48.880031 $244401.0000 $5000.0200
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 17.285714 $4003.7100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 252 283 314.576030 $15728.8100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 27 29 19.928085 $996.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 32 34 51.655480 $1291.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 329 408 1106.598433 $55330.0400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 16 18 53.300002 $2665.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 11 12 8.533334 $213.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 152 180 468.119058 $23406.0100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 9 11 36.276190 $1813.8100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 10 10 36.942857 $923.5700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 129 157 417.430173 $20871.5900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 9 16.077777 $803.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 22.609522 $565.2400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 175 209 532.374614 $26618.7900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 14 15 21.711111 $1085.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 8 16.733333 $418.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 110 118 1162.428573 $58121.4900 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 9.000000 $450.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1276 1614 13807.004773 $690350.7000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 153 187 1545.028578 $77251.4300 $50.0000
INTR -T1013 INTERPRETER 149 220 728.552378 $36427.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1578 2467 20046.557169 $240558.8700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 84 609.642859 $43869.9300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 9.942857 $715.4900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.066667 $176.6400 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 13.085715 $941.6500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 125 149 1245.471427 $89624.2000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 13.142857 $945.7600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 8 8 56.390477 $4057.8500 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 5 0.934247 $107.2700 $114.8200
SENS -V5060 BEHIND EAR HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 6 8 7.351293 $133.2800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 116 139 1204.566665 $86680.6800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 13 142.714287 $10269.7100 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.300000 $132.4800 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 26.047619 $1874.3900 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 13.142857 $945.7600 $71.9600
TRAV -TRAVS Travel by mile 1590 2500 20120.528600 $8953.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 1688 8979 63958.931642 $1754253.8900 $27.4300
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Total 10292 66358.305523 $1891141.8600 $28.5000
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Number of Children (Unduplicated) With at Least One Authorization 1896