Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 55
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4151 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 50 52 549.920636 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 62 67 8378.700000 $310011.9000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 111 119 8928.620636 $310011.9000 $34.7200
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.323288 $14.5500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.244444 $28.1100 $114.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 31 33 32.074733 $1603.7300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 53 55 98.142857 $4907.1500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 17 17 34.000000 $2550.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 205 206 430.000000 $32250.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 48.000000 $3600.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 77 79 158.000000 $11850.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 38 38 94.000000 $7050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 31 32 63.000000 $3496.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 57 59 118.000000 $6549.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 66 76 23.681745 $1208.9500 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 12 13 4.622221 $235.9600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 17.324603 $884.4200 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 5 5 3.505555 $178.9600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 85 96 46.905553 $2394.5200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 31 34 10.281745 $524.8800 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 6 7 3.372222 $172.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.511111 $77.1400 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.033333 $1.7000 $51.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 37 44 24.772222 $1264.6200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 2.394444 $122.2300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 162 178 80.844440 $4127.0800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 24 24 10.727776 $547.6400 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.438889 $22.4100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 3.549999 $181.2200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.083333 $48.2600 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.100000 $4.4600 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 570 1084 1375.095624 $90436.8500 $65.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 3.961111 $19805.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.733333 $36.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.655556 $32.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.211111 $508.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 5 2.811111 $140.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 5 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 6 1.533335 $38.3400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 270 332 272.822208 $13641.0400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 3 1.022222 $51.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 238 284 392.365071 $9809.1100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 150 302 240.146804 $12007.2400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 1.261111 $63.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 86 171 238.173820 $5954.3700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 100 70.888892 $3544.4600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 31 76 94.616669 $2365.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 230 273 232.161096 $11607.9800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.861111 $43.0600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 224 263 329.566658 $8239.1500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 13.142857 $328.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 316 392 3470.390456 $173519.7700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 12 117.571428 $5878.5900 $50.0000
INTR -T1013 INTERPRETER 2 3 6.285714 $314.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 128 148 1209.323804 $86394.1700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 14 16 80.642857 $5761.1300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 113 136 1344.635709 $76913.2500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 8 9 57.428571 $3284.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 40 49 398.511109 $28469.6500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 10.285715 $734.8100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 47 62 558.250000 $31909.6000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 31.857142 $1820.9600 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.394521 $317.9500 $228.0000
SENS -V5264 EARMOLD 4 4 3.977777 $71.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 183 233 1968.214273 $140609.3800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 10 69.285714 $4949.7700 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 22 24 233.857141 $16706.7800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 4 16.714286 $1194.0700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.000000 $152.6800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 4.000000 $148.0000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 629 2948 11496.560293 $667568.2900 $58.0700
-------------------------------------------------------------------------------------------------------------------------------------
Total 4151 21800.276553 $1068017.0500 $48.9900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 796