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: 10-01-21 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 4127 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 25 28 2396.322223 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 105 124 13730.982538 $508046.3500 $37.0000
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Subtotal (Total Children Is Unduplicated) 128 152 16127.304761 $508046.3500 $31.5000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 5 3.788888 $435.7100 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 30 32 40.664002 $2033.2000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 55 55 102.000000 $5100.0000 $50.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 26 26 52.000000 $3900.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 146 147 292.285714 $21921.4300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 30.000000 $2250.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 24 25 48.142857 $3610.7200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 63 66 130.285714 $9771.4300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 40.000000 $2220.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 72 72 144.000000 $7992.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 14 28.000000 $2100.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 77 95 48.890473 $2495.8500 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 4 4 2.444444 $124.7900 $51.0500
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.188889 $9.6400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 17 17 10.961112 $559.5700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 97 109 64.449616 $3290.1400 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 46 58 19.450003 $992.9400 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.511111 $26.0900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.233333 $62.9600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 36 43 23.427778 $1195.9900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.005556 $0.2900 $51.4600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 161 192 70.980159 $3623.5500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 7 9 2.794444 $142.6500 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.911111 $46.5100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.511111 $26.0900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 0.794445 $35.4000 $44.5500
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Subtotal (Total Children Is Unduplicated) 560 1046 1211.726316 $77495.2700 $63.9500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.961111 $4805.5000 $4999.9400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 3.200000 $160.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 2.400000 $120.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.977778 $454.8900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 2 2.000000 $100.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 8 4.633335 $115.8400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 214 282 226.656348 $11332.8100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 201 258 336.872225 $8421.8100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 148 329 208.399993 $10419.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 99 209 232.416666 $5810.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 99 61.422218 $3071.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 37 87 99.888888 $2497.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 185 231 186.266666 $9313.3300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.388889 $19.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 190 241 289.927783 $7248.2100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 17.821428 $445.5400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 281 364 3112.709492 $155635.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 9 11 60.928572 $3046.4400 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 144 179 1239.190466 $88527.9000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.428571 $387.8200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 150 194 1840.642848 $105284.8500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 31.714285 $1814.0600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 61 80 602.714278 $43057.9700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 13.142857 $938.9300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 52 72 696.999996 $39840.5400 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 3 2.460274 $560.9500 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.044444 $1388.2500 $455.9900
SENS -V5264 EARMOLD 6 8 6.233332 $112.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 170 226 1863.138076 $133102.7400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 24.499999 $1750.2800 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 12 14 147.499999 $10537.4100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 26.285714 $1877.8600 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.066667 $42.5700 $13.8800
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Subtotal (Total Children Is Unduplicated) 615 2929 11356.933198 $652342.5600 $57.4400
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Total 4127 28695.964275 $1237884.1700 $43.1400
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Number of Children (Unduplicated) With at Least One Authorization 796