Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 02
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 4569 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 2 2 4.541270 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 4.541270 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 37 46 23.604032 $1144.8000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 4 1.312328 $73.6300 $56.1000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 5 2.427397 $35.6300 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.172603 $19.9900 $115.8100
EXIT -EXIT EXIT ASSESSMENT 19 19 28.428571 $1421.4300 $50.0000
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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 78 80 158.505479 $11887.9100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 30 30 59.500000 $4462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 37 39 78.000000 $5850.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 19 19 37.500000 $2812.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 92 101 197.005479 $10933.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 10 20.000000 $1110.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 29 58.000000 $4350.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 10 12 22.500000 $1687.5000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 3.000000 $150.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 31 37 24.464481 $1257.7200 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.366667 $18.8500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 27 29 15.556238 $799.7500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 4 21.350294 $1097.6200 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 3 10.532290 $541.4700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 13 5.308902 $272.9400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 4 1.200000 $61.6900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 26 29 12.035844 $618.7700 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.246575 $12.6800 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 18 9.404792 $483.5000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 5 8 1.232877 $63.3900 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 3.972906 $204.2500 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.246575 $12.6800 $51.4200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.585464 $30.1000 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 36 41 27.631137 $1420.5300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.550000 $28.2800 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.400000 $20.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 3.232877 $166.2000 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 1.164384 $59.8600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 38 42 26.210881 $1347.5100 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.606849 $134.0200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $9.4200 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.588889 $71.2800 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 0.616666 $27.6600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 36.000000 $1905.4700 $52.9300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 309 675 911.311477 $57601.9900 $63.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 46 56 153.669514 $768346.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.180822 $9.0400 $49.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 41 44 69.895400 $3494.7800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 4 6.005556 $300.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.966667 $49.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 306 420 870.426552 $43521.3300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 3.300000 $165.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 162 206 410.127532 $20506.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 7.066667 $176.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 38 71.228570 $3561.4200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 290 365 716.626553 $35831.3500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.000000 $150.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.133334 $153.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 9 102.857143 $5142.8500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 275 350 2802.700010 $140134.8200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 43 51 407.928571 $20396.4300 $50.0000
INTR -T1013 INTERPRETER 28 44 140.000001 $7000.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 360 930 4690.767407 $46907.6300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 89 106 962.057146 $69229.5600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 12.857143 $925.2000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.714286 $501.9400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 73 83 819.857147 $58996.8200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 8.571429 $493.3700 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.345205 $308.8700 $229.6100
SENS -V5264 EARMOLD 2 2 1.517808 $27.5200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 101 115 979.552383 $70488.5400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 6 46.142857 $3320.4400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 12.857143 $179.4900 $13.9600
TRAV -TRAVS Travel by mile 391 1043 251797.335393 $112049.8100 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 447 3892 265115.688239 $1412600.1700 $5.3300
-------------------------------------------------------------------------------------------------------------------------------------
Total 4569 266031.540986 $1470202.1600 $5.5300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 472