Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 4267 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 27 27 41.125393 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 27 41.125393 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 36 37 31.755556 $1781.4900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 26 29 23.272221 $368.6300 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 25 31 24.850000 $484.8200 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 3.511111 $51.5400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 9 10 18.231747 $402.3800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 5 3.133334 $27.6100 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 22 21.866667 $632.3900 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 87 93 61.744434 $852.6800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 14 16 35.044444 $737.3300 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.000000 $135.9600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.000000 $463.2400 $115.8100
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 12 24.000000 $1800.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 23 30 30.022222 $1543.4400 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 52 58 44.116666 $2268.0300 $51.4100
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 1.022222 $52.5500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 8 6.511111 $334.7400 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 30 34 21.755555 $1118.4500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 3.000000 $154.2300 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 1.344444 $69.1200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 18 18.000000 $925.3800 $51.4100
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 1 1 0.511111 $26.2800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 17 18 10.494444 $539.5200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.338889 $68.8300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 15 11.722222 $602.6400 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 74 89 78.415080 $4031.3300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.161111 $59.6900 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 3 0.511111 $26.2800 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 7 4.172222 $214.4900 $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 0.094444 $4.8500 $51.3900
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 85 102 65.694443 $3377.3400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 6.811111 $350.1600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.022222 $52.5500 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 3.000000 $154.2300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 9 4.572222 $235.0600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 7 39.714286 $2041.7100 $51.4100
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Subtotal (Total Children Is Unduplicated) 473 703 637.416652 $27565.6000 $43.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 6.200000 $429.9700 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 16 16 19.733333 $4570.6300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 157 206 204.867669 $10243.4500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 4 6.066667 $303.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 4.583333 $114.5800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 518 682 1947.019061 $97351.0100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 5 12.233333 $611.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.500000 $37.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 275 334 817.142876 $40857.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 7.100000 $177.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 97 115 292.009531 $14600.5100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.866667 $43.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 271 346 813.100024 $40655.1200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 6.300000 $315.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.466667 $186.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 28 28 308.633332 $15431.6900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 953 1236 11716.334094 $585817.0300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 125 150 1396.559523 $69828.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 97 114 1217.999998 $87647.3300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 44 50 544.571428 $39187.4200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 4 39.428571 $2837.2900 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 3 3 4.000000 $918.4400 $229.6100
SENS -V5264 EARMOLD 6 6 29.303174 $531.2700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 161 199 1664.461903 $119774.7300 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 10 14 199.000000 $11462.4100 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 3 3 23.714286 $1365.9400 $57.6000
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Subtotal (Total Children Is Unduplicated) 1143 3537 21292.195470 $1150324.0400 $54.0300
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Total 4267 21970.737515 $1177889.6400 $53.6100
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Number of Children (Unduplicated) With at Least One Authorization 1182