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: 10-01-21 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 2078 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 6 7 4.822221 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 7 4.822221 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.277778 $18.6300 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.277778 $12.5100 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.277778 $36.7000 $28.7200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.277778 $26.6900 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.298630 $13.4400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.528767 $60.8100 $115.0100
EXIT -EXIT EXIT ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 15 16 17.833333 $910.3900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 7.000000 $357.3500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 20 21 21.000000 $1072.0500 $51.0500
SCREEN-T1023 SCREENING 67 68 68.000000 $3400.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 15 15.000000 $765.7500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 15 15 17.066667 $760.3200 $44.5500
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Subtotal (Total Children Is Unduplicated) 125 161 158.838509 $7751.5000 $48.8000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.800000 $140.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 1.866667 $93.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 316 414 1139.469047 $56973.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 192 258 755.966664 $37798.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 94 115 358.000002 $17900.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 227 279 726.404768 $36320.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 4 6.133333 $153.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 357 442 2715.867852 $135793.5300 $50.0000
INTR -T1013 INTERPRETER 8 9 67.647618 $3382.3800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 69 318.621432 $22762.3300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 3.066667 $219.0900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 20 121.776190 $6965.6100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 5 30.523809 $1745.9600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 57 68 424.613092 $30334.3800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.100000 $150.0200 $71.4400
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.678571 $324.5900 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.277778 $519.3400 $228.0000
SENS -V5264 EARMOLD 2 2 2.144445 $38.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 213 1299.892857 $92864.4400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.000000 $500.0800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 10.309525 $143.1000 $13.8800
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Subtotal (Total Children Is Unduplicated) 526 1910 8002.160317 $445122.1500 $55.6300
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Total 2078 8165.821047 $452873.6600 $55.4600
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Number of Children (Unduplicated) With at Least One Authorization 536