Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 52
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: 07-01-22 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 4173 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 16 17 17.244446 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 17 17.244446 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 6.166667 $90.5300 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 6.166667 $54.3300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 6.166667 $178.3400 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 6.166667 $129.7500 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.506849 $22.9700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.506849 $58.6900 $115.8000
EVAL -96111 DEVELOPMENTAL EVALUATION 3 3 3.000000 $150.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 14 16 16.000000 $822.5600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 17 17 17.000000 $873.9700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 4 4.000000 $205.6400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 6.000000 $308.4600 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 16 17 22.166667 $1139.5900 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SCREEN-T1023 SCREENING 154 164 166.343378 $8317.1700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 30 32 32.000000 $1645.1200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 13 14 19.200000 $987.0700 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.8200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 19 21.500000 $1105.3200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $102.8200 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 7 99.409524 $5110.6400 $51.4100
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Subtotal (Total Children Is Unduplicated) 236 316 443.299935 $21765.6400 $49.1000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 6.166667 $308.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 6 36.433333 $1821.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 466 876 4709.450006 $235472.5300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 21.000000 $1050.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 5.466667 $136.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 283 477 2886.057145 $144302.8700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 129 264 1661.133337 $83056.6900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 276 448 2331.533333 $116576.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 13 20 99.314286 $2482.8600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 3.100000 $77.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.100000 $77.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 5 34.004763 $1700.2400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 620 1038 11544.098824 $577204.8500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 6 52.209524 $2610.4700 $50.0000
INTR -T1013 INTERPRETER 5 6 67.380953 $3369.0500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 84 136 1224.077378 $88084.5900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 5 35.066667 $2523.4000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 32 48 604.242854 $34804.3900 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 2 16.733334 $963.8400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 82 145 1306.795237 $94037.0200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 5 6 45.842857 $3298.8600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 14 24 313.128570 $18023.6900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 2.266667 $130.4700 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 12.200000 $877.9100 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 2 12.700000 $913.8900 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 36.000000 $2072.1600 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 2.055556 $37.2700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 200 301 2952.758326 $212480.4700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 8 107.628572 $7744.9500 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 3 17.600000 $1266.5000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.033333 $42.3400 $13.9600
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Subtotal (Total Children Is Unduplicated) 852 3840 30154.578189 $1638008.8300 $54.3200
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Total 4173 30615.122570 $1659774.4700 $54.2100
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Number of Children (Unduplicated) With at Least One Authorization 872