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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2300 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 1 2 1.022223 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 2 1.022223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.379300 $46.8700 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.379300 $30.6800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.379300 $94.0500 $27.8300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.379300 $75.7000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.528767 $23.8000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.528767 $60.8100 $115.0100
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 13.000000 $663.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 7.000000 $357.3500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 11 11 11.800000 $602.3900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SCREEN-T1023 SCREENING 60 61 61.933333 $3096.6700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 6.285714 $320.8900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 4.000000 $204.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 26 27 27.200000 $1388.5600 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 116 148 151.793781 $7267.7100 $47.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.212698 $26063.0000 $4999.9100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 6.433334 $321.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 4 11.566667 $828.2900 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 19 21.416668 $1070.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.366667 $34.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 316 496 1347.683334 $67384.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 208 302 872.733335 $43636.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 99 143 396.942852 $19847.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 220 282 738.833338 $36941.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.200000 $80.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 321 417 2478.299993 $123915.0900 $50.0000
INTR -T1013 INTERPRETER 15 18 187.133333 $9356.6600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 119 585.936503 $41859.3500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 32 45 332.976189 $19046.2400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 72 103 597.911904 $42714.8300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 3.176190 $181.5500 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.022222 $461.0600 $228.0000
SENS -V5264 EARMOLD 5 6 11.344445 $204.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 175 1060.276182 $75746.1800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 7 30.199999 $419.1800 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 518 2150 8694.665853 $510111.9700 $58.6700
-------------------------------------------------------------------------------------------------------------------------------------
Total 2300 8847.481857 $517379.6800 $58.4800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 523