Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 57
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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 8945 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 9 9 22.468255 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 100 111 122.083330 $4541.4900 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 109 120 144.551585 $4541.4900 $31.4200
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $58.5300 $19.5100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.200000 $26.4800 $22.0700
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -V5010 ASSESSMENT FOR HEARING AID 44 49 49.000000 $2220.6800 $45.3200
OCTF -97168 OT RE-EVAL EST PLAN CARE 66 103 65.657146 $3375.4500 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.8200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 1.755555 $90.2500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 80 80 55.266667 $2841.2600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.816667 $41.9900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 2.144444 $110.2400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 40 64 43.419048 $2232.1800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 40 41 65.038889 $3343.6500 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.461111 $75.1200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.222222 $11.4200 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 107 163 122.692064 $6307.6000 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 36 17.361113 $892.5400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 6 4.455557 $229.0700 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 244 563 439.490483 $22106.8600 $50.3000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.855556 $59.3400 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 2.050000 $102.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1187 1850 3368.339662 $168416.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 149 260 711.619048 $35580.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1348 2054 3242.417439 $162120.7700 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 56.285713 $1407.1500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 143 348 3425.814272 $85645.3500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 21.995238 $1099.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1700 2754 42181.734905 $2109086.9700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 2 10.285715 $514.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 12 12 132.714286 $1592.5700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 141 324 2258.714285 $162537.1200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 2 37.142857 $2672.8000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 8 13.347618 $768.8200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 75 185 1419.071428 $102116.3900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 6 33.571429 $1932.3600 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 174 384 2682.950788 $193065.2300 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.285714 $189.2600 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 2 30.285715 $1744.4600 $57.6000
TRAV -TRAVS Travel by mile 35 56 701.096826 $311.9900 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1760 8262 60334.578494 $3031015.0000 $50.2400
-------------------------------------------------------------------------------------------------------------------------------------
Total 8945 60918.620562 $3057663.3400 $50.1900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1789