Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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 8242 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.866667 $32.2400 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 6 6 3.944443 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7 7 4.811110 $32.2400 $6.7000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $31.6800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 625 661 660.755556 $12891.3400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 7.000000 $165.6900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 530 558 557.188889 $8179.5300 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 528 555 554.188889 $4882.4000 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 521 548 547.188889 $15824.7000 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $41.4300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 523 551 550.188889 $11575.9700 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 66 69 69.000000 $5183.9700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $181.2800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.000000 $579.0500 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 9 11 21.633335 $1081.6800 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 83 100 108.879364 $5597.4800 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 24 27 37.000000 $1902.1700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 123 152 156.974603 $8070.0600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 1.142857 $58.7600 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 819 3257 3288.141271 $76401.4300 $23.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 8.000000 $40000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 432 607 832.085723 $41604.3500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 73 77.249205 $3862.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 153 197 224.744442 $11237.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 262 337 438.731750 $21936.6000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 24.511905 $1225.6000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.177778 $8.8900 $50.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1250 1844 16013.818642 $800691.3700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 38.000000 $1900.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 396 544 4240.633348 $305155.9600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 26.285714 $1891.5200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 425 603 3790.830186 $272787.9400 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.000000 $688.8300 $229.6100
SENS -V5264 EARMOLD 2 2 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 528 752 5582.533359 $401719.1200 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1749 4978 31303.602052 $1904764.2200 $60.8500
-------------------------------------------------------------------------------------------------------------------------------------
Total 8242 34596.554433 $1981197.8900 $57.2700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1791