Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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 3052 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 59 64 102.136508 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 59 64 102.136508 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.022222 $350.0000 $115.8100
EXIT -EXIT COS Exit 1 1 2.000000 $100.0000 $50.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 23 25 29.066667 $4134.1600 $142.2300
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Subtotal (Total Children Is Unduplicated) 24 29 34.088889 $4584.1600 $134.4800
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 12 13 14.911112 $1034.0900 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.888889 $61.6500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 114 125 90.598357 $4529.9400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 38 44 54.415080 $2720.7600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 88 92 46.312326 $1157.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 25 28 56.100000 $2805.0000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 8 13.071429 $653.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 8 9.588888 $239.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 13 25.683334 $1284.1700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 6 10.504762 $525.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 6.272222 $156.8100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 21.700000 $1085.0000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 1.533333 $76.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 4 9.795238 $244.8800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 8.816667 $440.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 3.150000 $78.7500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 30 40 1188.857145 $29721.4200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 26 889.142860 $22228.5600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.571428 $828.5800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 44.428571 $2221.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 754 1019 8055.257147 $402763.1600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 56 68 471.485716 $23574.3000 $50.0000
INTR -T1013 INTERPRETER 46 65 387.492857 $19374.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 797 1127 8863.342866 $106360.2000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 37 233.657940 $16814.0300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 7 8 65.698414 $4727.6600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 11 15 78.850000 $4541.7500 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 40.714286 $2345.1400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 32 44 262.721428 $18905.4500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 8 9 27.035715 $1945.4800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 12 16 110.357144 $6352.1500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 5 6 32.964286 $1897.4300 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 18 24 35.111112 $636.5700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 61 405.319054 $29166.7300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 12 98.142857 $7062.3600 $71.9600
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Subtotal (Total Children Is Unduplicated) 953 2959 21686.492463 $720402.8100 $33.2200
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Total 3052 21822.717860 $724986.9700 $33.2200
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Number of Children (Unduplicated) With at Least One Authorization 998