Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 06
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 3355 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 83 96 137.414286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 83 96 137.414286 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.000000 $345.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 24 24 48.000000 $2400.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 26 27 51.000000 $2745.0000 $53.8200
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.200000 $110.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 25 34 43.622223 $2181.1200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.000000 $1150.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 82 88 22.480449 $1124.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 1.011112 $50.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 70 72 23.816995 $595.4400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 9 11 18.833334 $941.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 10 10 17.066667 $426.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 9 15.383333 $769.1700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 4.200000 $210.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 7.366667 $184.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 7.566668 $378.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 11.300000 $565.0000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.800000 $195.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 52 66 1889.714287 $47242.8400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 862 1136 8777.847598 $438893.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 32 226.857140 $11342.8900 $50.0000
INTR -T1013 INTERPRETER 24 27 345.928568 $17296.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 965 1345 10581.696005 $105817.1100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 49 298.583336 $21330.7700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 10 31.209524 $2229.6100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 20 95.400002 $5456.8700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 8 28.285715 $1617.9400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 53 68 346.071432 $24723.3300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 10 17 46.509526 $3322.6500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 13 62.000002 $3543.9000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 3 9.490476 $542.4800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 4.197260 $272.8200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 2 2.000000 $228.0000 $114.0000
SENS -V5060 BEHIND EAR HEARING AID 1 2 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 6 6 6.000000 $2736.0000 $456.0000
SENS -V5264 EARMOLD 21 30 31.511112 $567.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 112 575.709536 $41128.6400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 18 22 102.357144 $7312.3800 $71.4400
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Subtotal (Total Children Is Unduplicated) 1071 3232 23654.082777 $745095.4300 $31.5000
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Total 3355 23842.497063 $747840.4300 $31.3700
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Number of Children (Unduplicated) With at Least One Authorization 1142