Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 53
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: 04-01-21 and 06-30-21 Date of Report: 07-15-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1441 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 9 9 14.416666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 3.600000 $133.2000 $37.0000
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Subtotal (Total Children Is Unduplicated) 12 13 18.016666 $133.2000 $7.3900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 4 4.000000 $194.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 8 8 6.338889 $358.0800 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.011111 $23.7500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 4.011113 $55.6400 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 48 48 26.455561 $627.0100 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.505556 $42.9000 $84.8500
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Subtotal (Total Children Is Unduplicated) 72 75 42.322230 $1301.3800 $30.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 16.000000 $80000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.966667 $140.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 11 11 7.655557 $1760.8100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 4.005556 $200.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 10 9.500000 $475.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 9.705556 $485.2800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 14 14 36.627778 $1831.4000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 33 38 52.584921 $2629.2500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 60 68 86.894445 $4344.7300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 8.033333 $200.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 9 13.933333 $696.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 25 28 67.839680 $3391.9800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 22 27 35.461111 $1773.0600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 34 38 59.509524 $2975.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 8 9 9.005556 $225.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 152 166 1008.601188 $50430.0800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 394 470 2902.980157 $145149.0000 $50.0000
INTR -T1013 INTERPRETER 1 1 3.033333 $151.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 95 128 411.182539 $4111.8200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 24 96.055555 $6862.2000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 11 73.171430 $5227.3700 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 6 6 25.428570 $1816.6100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 59 69 355.140477 $25371.2600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 10 42.073809 $3005.7400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 9 35.604762 $2543.6000 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 7 7 6.300000 $450.0700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 41 52 264.347619 $18885.0000 $71.4400
SENS -V5264 EARMOLD 1 1 0.933333 $16.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 17 39.703968 $2836.4500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 12 96.766666 $6913.0100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 13 13 56.988890 $4071.2900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 60 78 500.390479 $35747.9300 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 6.066666 $84.2000 $13.8800
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Subtotal (Total Children Is Unduplicated) 705 1353 6346.492458 $414904.8400 $65.3800
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Total 1441 6406.831354 $416339.4100 $64.9800
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Number of Children (Unduplicated) With at Least One Authorization 712