Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
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 4416 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 1 0.644444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.644444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 631 652 663.882538 $15601.2400 $23.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 26.285714 $1341.8900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 14 11.211111 $572.3300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 52 53 89.100000 $4548.5600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.400000 $122.5200 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 10.066667 $513.9000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 12.428571 $634.4800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 6.655556 $339.7700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 60 68 65.522223 $3344.9100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 6.022222 $268.2900 $44.5500
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Subtotal (Total Children Is Unduplicated) 722 826 896.574602 $27413.4800 $30.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.022222 $15111.0000 $4999.9600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $137.7200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 18.428571 $4238.5800 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 279 314 447.419844 $22371.0200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 54 71.100003 $3555.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 76 80 103.240473 $5162.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 177 189 247.466669 $12373.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.900000 $47.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1028 1351 13789.513813 $689475.8500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 13.142857 $657.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 357 433 3512.823819 $250956.2200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.857143 $204.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 22 24 155.607143 $8900.7400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 457 566 3924.545275 $280369.4700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 12 73.928570 $4225.7700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 24.571429 $1404.5000 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 429 526 4237.270634 $302710.8200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 21.785714 $1556.3700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.357143 $77.6300 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 11 11 46.142857 $640.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 1467 3589 26699.124179 $1604225.2700 $60.0900
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Total 4416 27596.343225 $1631638.7500 $59.1300
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Number of Children (Unduplicated) With at Least One Authorization 1480