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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2050 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 6 5.277777 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 5.277777 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.5800 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.7900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.7200 $28.7200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 17 18 18.000000 $918.9000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 9.000000 $459.4500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 13 13 13.000000 $663.6500 $51.0500
SCREEN-T1023 SCREENING 53 58 65.428571 $3271.4300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 16 16.666667 $850.8400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 13 15 14.266667 $635.5800 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 9.819047 $516.1800 $52.5700
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Subtotal (Total Children Is Unduplicated) 106 143 157.180952 $7738.0800 $49.2300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 3.000000 $150.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 306 434 1075.195240 $53759.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.750000 $18.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 179 244 697.866665 $34893.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 97 128 369.233331 $18461.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 227 281 710.261904 $35513.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 6.000000 $150.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 352 466 2649.466658 $132473.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.571429 $28.5700 $50.0000
INTR -T1013 INTERPRETER 4 4 21.466666 $1073.3300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 61 306.804763 $21918.1100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.233333 $88.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 20 98.295238 $5622.4800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 3 5 23.880953 $1365.9900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 52 70 368.638096 $26335.4900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 29.142857 $1665.8100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 26.942857 $1540.0500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 172 1063.356346 $75966.1500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.142857 $10.2100 $71.4600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.533333 $38.1000 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 8.666667 $120.2900 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.466667 $62.0000 $13.8800
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Subtotal (Total Children Is Unduplicated) 496 1901 7465.915860 $411254.5400 $55.0800
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Total 2050 7628.374589 $418992.6200 $54.9300
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Number of Children (Unduplicated) With at Least One Authorization 504