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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4901 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 7.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 7.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 50 62 31.417580 $1523.7600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 4 2.498630 $140.1700 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 5 3.389041 $49.7500 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 1.260426 $57.1200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.498630 $57.7400 $115.8000
EXIT -EXIT EXIT ASSESSMENT 25 25 31.712264 $1585.6200 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 72 76 128.341222 $9625.6100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 27 31 59.000000 $4425.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 32 61.500000 $4612.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 21 22 42.000000 $3150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 72 87 147.060269 $8161.8600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 18 20 39.000000 $2164.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 22 24 40.500000 $3037.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 11 21.500000 $1612.5000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 38 44 19.007076 $977.1400 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.622222 $31.9900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 25 29 9.792846 $503.4500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 5 26.413699 $1357.9300 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.142466 $7.3300 $51.4200
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 13.249315 $681.1500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 13 3.952967 $203.2200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 1.121537 $57.6600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 27 33 23.691263 $1217.9900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.052055 $2.6800 $51.4600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 16 19 8.209664 $422.0600 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 5 5 0.939726 $48.3100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 7 2.248402 $115.6000 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.126027 $6.4800 $51.4000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.030137 $1.5500 $51.3500
SPCH -92521 EVAL OF SPEECH FLUENCY 43 51 45.478985 $2338.0800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 0.816666 $41.9800 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.272222 $13.9900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 1.777092 $91.3600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.106849 $5.4900 $51.3900
SPCH -92522TL EVAL OF SPCH SOUND PROD 3 3 1.391781 $71.5500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 27 17.684474 $909.1600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 6.819950 $350.6200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 5 1.516895 $77.9800 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 0.754871 $38.8100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 39.000000 $2004.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 305 680 838.463916 $51984.1500 $62.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 55 68 157.127310 $785637.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 2 1.011111 $234.1900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 42 48 77.170915 $3858.5400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 3 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 331 444 948.669009 $47433.2500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.966667 $98.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 188 228 466.927069 $23346.2400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 7.099999 $355.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 9.100000 $227.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 37 81.599997 $4079.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 321 395 795.181709 $39758.9100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.433333 $121.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 5.400000 $135.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 11 12 75.142857 $3757.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 294 359 2951.951584 $147597.5800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 57 66 522.142856 $26107.1500 $50.0000
INTR -T1013 INTERPRETER 14 24 58.843703 $2942.1900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 380 1003 5033.608609 $60403.2500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 98 117 939.134921 $67580.1500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 30.857143 $2220.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 68 83 681.214288 $49020.1600 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 2 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 2 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 112 1071.404762 $77098.2900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 48.714285 $3505.4800 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 2 13.000000 $181.4800 $13.9600
TRAV -TRAVS Travel by mile 423 1187 295054.368435 $131299.2000 $0.4500
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Subtotal (Total Children Is Unduplicated) 470 4219 309044.820562 $1477762.8800 $4.7800
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Total 4901 309890.795589 $1529747.0300 $4.9400
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Number of Children (Unduplicated) With at Least One Authorization 491