Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
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 1910 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 42 45 68.770635 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 45 68.770635 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.911111 $21.4100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.911111 $21.4100 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.911111 $21.4100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.305555 $12.7800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.911111 $26.1700 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.911111 $40.7800 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.911111 $26.2000 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.911111 $19.0300 $20.8900
EXIT -EXIT EXIT ASSESSMENT 61 61 92.122832 $4606.1400 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.388889 $70.9000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.444444 $175.8400 $51.0500
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Subtotal (Total Children Is Unduplicated) 68 77 106.639497 $5093.1200 $47.7600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 4.066667 $203.3400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 152 210 148.590717 $7429.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 16 16 19.216668 $480.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 546 729 2186.981181 $109349.2300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 4 4 15.200000 $760.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 7 8.300000 $207.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 265 321 840.338122 $42017.0400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 6.300000 $315.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 9.633333 $240.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 98 128 335.148100 $16757.4600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.066667 $76.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 273 330 837.885746 $41894.4300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 3 9.638095 $481.9100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 12.466667 $311.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 14 19 189.352380 $9467.6300 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 3 4 30.428571 $2173.8200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 9.428571 $673.5800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.857143 $418.4300 $71.4400
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Subtotal (Total Children Is Unduplicated) 622 1788 4672.898628 $233327.3800 $49.9300
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Total 1910 4848.308760 $238420.5000 $49.1800
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Number of Children (Unduplicated) With at Least One Authorization 674